Manual of Valvular Heart Disease [1st ed.] 1496310128, 9781496387233, 9781496310125

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Manual of

VALVULAR HEART DISEASE

Senior Acquisitions Editor: Sharon Zinner Development Editor: Ashley Fischer Editorial Coordinator: Lauren Pecarich Marketing Manager: Rachel Mante Leung Production Project Manager: Linda Van Pelt Design Coordinator: Holly McLaughlin Manufacturing Coordinator: Beth Welsh Prepress Vendor: S4Carlisle Publishing Services Copyright © 2018 Wolters Kluwer. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data Names: Asher, Craig R., editor. | Griffin, Brian P., 1956– editor. Title: Manual of valvular heart disease / [edited by] Craig R. Asher, Brian P. Griffin. Description: Philadelphia: Wolters Kluwer Health, [2018] | Includes bibliographical references. Identifiers: LCCN 2017022873 | eISBN 9781496381682 Subjects: | MESH: Heart Valve Diseases | Heart Valves—surgery Classification: LCC RC685.V2 | NLM WG 260 | DDC 616.1/25—dc23 LC record available at https://lccn.loc.gov/2017022873. This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

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Craig R. Asher, MD Staff Cardiologist Department of Cardiology Cleveland Clinic Florida Weston, Florida

Roger Byrne, MD Advanced Imaging Fellow Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Joseph Campbell, MD Interventional Cardiology Fellow Department of Cardiology Massachusetts General Hospital Boston, Massachusetts

Patrick Collier, MD, PhD Staff Cardiologist Section of Imaging Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Paul C. Cremer, MD Staff Cardiologist Section of Imaging Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Milind Y. Desai, MD Staff Cardiologist Section of Imaging

Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Eoin Donellan, MD Fellow in Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

A. Marc Gillinov, MD Chairman Department of Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland, Ohio

Andrew L. Goodman, MD Staff Cardiologist Centennial Hospital Nashville, Tennessee

Brian P. Griffin, MD Section Head Imaging Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Richard A. Grimm, DO Director Echocardiography Laboratory Section of Imaging Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Divya Gumber, MD Resident in Internal Medicine Cleveland Clinic Cleveland, Ohio

Serge C. Harb, MD Advanced Imaging Fellow Department of Cardiovascular Medicine

Cleveland Clinic Cleveland, Ohio

Terence Hill, MD Fellow in Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Syed T. Hussain, MD Staff Surgeon Department of Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland, Ohio

Christine L. Jellis, MD, PhD Staff Cardiologist Section of Imaging Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Douglas R. Johnston, MD Surgical Director Aortic Valve Center Department of Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland, Ohio

Brandon M. Jones, MD Interventional Cardiology Fellow Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Samir R. Kapadia, MD Director Sones Cardiac Catheterization Laboratory Section Head Interventional Cardiology Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Srikanth Koneru, MD Fellow in Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Amar Krishnaswamy, MD Associate Program Director Interventional Cardiology Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Deborah H. Kwon, MD Staff Cardiologist Section of Imaging Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Stephanie L. Mick, MD Staff Surgeon Department of Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland, Ohio

Gian M. Novaro, MD Director Echocardiography Laboratory Department of Cardiology Cleveland Clinic Florida Weston, Florida

Jayendrakumar S. Patel, MD Fellow in Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Gösta B. Pettersson, MD, PhD Vice Chairman Department of Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland, Ohio

Dermot Phelan, MD, PhD Director Sports Cardiology Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Lourdes R. Prieto, MD Director Pediatric Catheterization Laboratory Department of Pediatric Cardiology Cleveland Clinic Cleveland, Ohio

Grant W. Reed, MD Interventional Cardiology Fellow Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

L. Leonardo Rodriguez, MD Associate Director Echocardiography Laboratory Section of Imaging Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Ellen Mayer Sabik, MD Staff Cardiologist Section of Imaging Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

William J. Stewart, MD Staff Cardiologist Section of Imaging Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

Balaji Tamarappoo, MD, PhD

Staff Cardiologist Cedar Sinai Medical Center Los Angeles, California

Maran Thamilarasan, MD Staff Cardiologist Section of Imaging Department of Cardiovascular Medicine Cleveland Clinic Cleveland, Ohio

E. Murat Tuzcu, MD Chairman Department of Cardiovascular Medicine Cleveland Clinic Abu Dhabi Abu Dhabi, United Arab Emirates

Patrick R. Vargo, MD Fellow in Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland, Ohio

rom the time the most elementary stethoscopes became available, physicians have been fascinated with valvular heart disease. Early on in training, medical students throughout the ages have been challenged to learn the signature sounds and signs of heart valve lesions. During the 20th century, the anatomy, pathophysiology, and natural history of most valvular heart diseases were well elucidated. Heart valve surgery became commonplace, though medical therapy, randomized trials, and nonsurgical therapies lagged far behind other cardiac conditions, like coronary artery disease. But times have changed. In the 21st century, valvular heart disease has rapidly emerged as an exciting and successful area of growth in the field of medicine. This resurgence is largely credited to the growth in multimodality cardiac imaging and earlier, lower risk interventions through percutaneous procedures and less invasive surgical options. The importance of valve disease is further illustrated by the development of valve clinics in medical centers throughout the country, a growing number of high-impact peer-reviewed manuscripts, courses and websites on the topic, guideline statements from major societies, and expanded coverage on many certifying examinations (general cardiology, interventional and echocardiography boards). Therefore, clinicians (cardiologists, cardiothoracic surgeons, cardiac anesthesiologists, and trainees) and ancillary personnel (technicians, sonographers, nurses, and physician assistants) caring for these patients require focused and up-to-date knowledge of the subject. The Cleveland Clinic is a leading center in the United States for the evaluation and treatment of valve disease. With this expertise, we have compiled an easily readable and referenced manual written by faculty at the institution. The Manual comprises 23 chapters including native and prosthetic valves; percutaneous pediatric and adult interventions and surgical procedures; cardiac imaging with three-dimensional echocardiography, computed tomography, and cardiac magnetic resonance imaging; echocardiography and cardiac catheterization laboratory hemodynamics, formulae, and cases; and a catheterization laboratory atlas, all specifically pertaining to valve disease. There

F

are plentiful figures and tables, key points, guideline statements, and even a question bank to review each chapter. We hope that this first edition of the Manual of Valvular Heart Disease will serve as an educational resource for caretakers providing the latest and best care for their patients. As two former program directors, we must always acknowledge the unyielding motivation, patience, and inspiration of our own families and our extended Cleveland Clinic family, most notably a superb cast of fellows and staff who contributed in countless ways to the production of this work and our careers. Craig R. Asher, MD, FACC, FASE Brian P. Griffin, MD, FACC

SECTION I

Native and Prosthetic Valve Diseases

1

Aortic Stenosis Divya Gumber, Eoin Donellan, and Patrick Collier

2

Aortic Regurgitation Roger Byrne and Dermot Phelan

3

Bicuspid Aortic Valve Disease Gian M. Novaro and Craig R. Asher

4

Mitral Stenosis L. Leonardo Rodriguez

5

Mitral Regurgitation Serge C. Harb and Brian P. Griffin

6

Tricuspid Valve Disease Balaji Tamarappoo

7

Pulmonary Regurgitation and Stenosis Serge C. Harb and Deborah H. Kwon

8

Prosthetic Valves Maran Thamilarasan

9

Infective Endocarditis Paul C. Cremer

SECTION II

Special Conditions

10

Special Considerations (Drugs, Pregnancy, Noncardiac Surgery, Anticoagulation, Valve-related Tumors) Ellen Mayer Sabik

SECTION III

Percutaneous and Surgical Valve Procedures

11

Percutaneous Mitral Valve Procedures Jayendrakumar S. Patel and Amar Krishnaswamy

12

Transcatheter Aortic Valve Replacement Brandon M. Jones, Amar Krishnaswamy, E. Murat Tuzcu, and Samir R. Kapadia

13

Pediatric Percutaneous Valve Procedures Lourdes R. Prieto

14

Surgery of the Mitral and Tricuspid Valves Patrick R. Vargo, Stephanie L. Mick, and A. Marc Gillinov

15

Valve Surgery: Aortic/Pulmonary Douglas R. Johnston

16

Valve Surgery: Endocarditis Gösta B. Pettersson and Syed T. Hussain

SECTION IV

Multimodality Imaging and Cardiac Catheterization Laboratory

Assessment

17

Computed Tomography/Magnetic Resonance Imaging Srikanth Koneru and Milind Y. Desai

18

Intraprocedural Echocardiography in Valve Disease William J. Stewart

19

3D Echocardiography Christine L. Jellis

20

Catheterization Hemodynamics and Formulae Grant W. Reed and Amar Krishnaswamy

SECTION V

Echocardiography and Cardiac Catheterization Cases and Calculations

21

Echocardiographic Calculations and Case Examples Terence Hill and Richard A. Grimm

22

Cardiac Cases and Calculations Joseph Campbell and E. Murat Tuzcu

SECTION VI

Atlas of Cardiac Catheterization Laboratory Hemodynamics

23

Atlas of Hemodynamic Tracings Andrew L. Goodman

Index

I.

INTRODUCTION Aortic stenosis (AS) is a common treatable cardiovascular problem whose prevalence is on the increase because of our aging population. From aortic sclerosis (focal areas of thickening and/or calcification) through worsening degrees of obstructive AS (characterized by more advanced valve thickening and calcification), the disease leads to ventricular dysfunction, symptoms, and death if untreated. The prevalence of aortic sclerosis is age dependent, ranging from 9% in a study in which the mean age was 54 years to 42% in a study in which the mean age was 81 years. Similarly, the prevalence of AS is age dependent, estimated at 1% of those aged over 65 years, 2.5% of those aged 75 years, and 8% of those aged 85 years.

II.

ETIOLOGY Age-related degenerative calcific disease (>50% of cases) is the most common etiology underlying AS, followed by congenital bicuspid aortic valve disease (30%–40% of cases) and postinflammatory rheumatic disease (50 mm in aortic disease associated

with bicuspid AV

APC, atrial premature contraction; AS, aortic stenosis; ASD, atrial septal defect; AV, aortic valve; LV, left ventricle; LVEF, left ventricular ejection fraction; MS; mitral stenosis; NYHA, New York Heart Association; PVC, premature ventricular contraction; VSD, ventricular septal defect; WHO, World Health Organization. From Regitz-Zagrosek, Lundqvist CB, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy. Eur Heart J. 2011;32(24):3147–3197.

3. Transthoracic echocardiogram—valve assessment and aortic size 4. In certain patients, functional capacity and symptoms should be assessed using stress testing. Prepregnancy symptoms often predict adverse outcomes during pregnancy or labor and delivery. One study found that women who achieve prepregnancy heart rate (HR) ≥150 bpm and/or peak oxygen uptake >25 mL/mg/min may be considered to have safer or better pregnancy outcomes. 5. Counseling on the basis of risk assessment to discuss maternal and fetal risks for complications and mortality. Discuss risks of therapy, including risk of miscarriage, early delivery, growth retardation resulting in small for gestational age infant, and possible fetal congenital defects. On the basis of risk, a discussion regarding contraception method should be included. These discussions are best approached by a multidisciplinary group including an obstetrician/gynecologist and a cardiologist. Women considered at high risk owing to valvular lesions should be considered for definitive treatment of the lesion before pregnancy. If valve surgery is needed, repair is preferable to replacement, and if replacement is needed, a careful discussion should occur regarding choice of prosthesis. Although a bioprosthesis is preferable because it does not require anticoagulation, it is not as durable as a mechanical prosthesis and will require reoperation sooner owing to degeneration. A bioprosthesis would allow a patient to go through her pregnancy without the risks of anticoagulation (bleeding risks, valve thrombosis, or even fetal teratogenesis in the first trimester). C. Patients at prohibitively high risk are those in WHO classification IV, who should be counseled against pregnancy. These include: 1. Severe symptomatic aortic stenosis (AS) or mitral stenosis (MS) 2. Cardiomyopathy with left ventricular ejection fraction (LVEF) ≤30% 3. Marfan syndrome with aortic root ≥45 mm 4. Advanced pulmonary hypertension (two-thirds systemic pressures)

5. Eisenmenger syndrome 6. History of peripartum cardiomyopathy with LVEF not fully recovered D. Cardiac considerations for contraception 1. Contraceptive options include combined hormonal contraceptives, progestin-only contraceptives, intrauterine devices (IUDs), barrier methods, and sterilization/permanent forms of contraception. 2. Specific issues include the increased risk of thromboembolic events and hypertension with estrogens. Thus, combined hormonal contraceptives (pills, patches, or vaginal rings) are not recommended for the following: a. Mechanical prostheses because of risk of valve thrombosis b. Eisenmenger syndrome because of risk of pulmonary embolism c. Intracardiac shunts because of risk of paradoxical embolus 3. Monthly injections with medroxyprogesterone are contraindicated in patients with CHF owing to risk of fluid retention. Barrier methods and IUDs releasing levonorgestrel are safest in patients with cardiomyopathy with decreased left ventricular (LV) function, pulmonary hypertension, and cyanotic heart disease. Patients with prohibitively high-risk pathology may wish to consider permanent forms of contraception. 4. In general, stenotic lesions are poorly tolerated, whereas regurgitant lesions are better tolerated. Although individual lesions will be discussed, including management, in further detail to understand the pathophysiology that occurs with valvular disease in pregnancy, one must first consider the normal physiologic/hemodynamic changes that occur with pregnancy. E. Physiologic and hemodynamic changes in pregnancy 1. Cardiac output increases 30% to 50% (increased HR and stroke volume). 2. Blood volume increases (beginning at 6 weeks, may continue until at least second trimester, although may continue throughout pregnancy); average increase 50% above baseline. 3. Systemic vascular resistance falls, causing systolic and diastolic blood pressure to drop by 10 mm Hg at the end of the second trimester, rising to or above prepregnancy level at term. F. Hemodynamic changes associated with labor and delivery 1. Cardiac output rises with contractions (80% above levels seen at

the end of the third trimester) as a result of increased sympathetic tone, increasing blood pressure (BP) and HR, and central blood volume increased by autotransfusion from uterine contractions. 2. Postdelivery preload increases further as the inferior vena cava (IVC) compression is relieved because the gravid uterus is no longer resting on the IVC. G. Treatment of specific valve lesions during pregnancy 1. Mitral stenosis a. The etiology of MS is usually rheumatic heart disease. Gradients are increased by the increased blood volume of pregnancy as well as by tachycardia. Mitral valve area is most reliably measured by direct planimetry during pregnancy. Functional mitral MS is more closely related to mean gradient across the valve. b. If symptomatic, β-blockers are the first-line drugs to decrease HR, improve left atrial emptying, and decompress the left atrium. Pulmonary edema is treated with diuretics. Heart failure is frequent with mitral valve area II. f. Vaginal delivery is recommended for mild MS or moderate MS with NYHA class I or II without pulmonary hypertension.

Cesarean section (C-section) should be considered for moderate or severe MS with class III or IV symptoms or if pulmonary hypertension is present despite medical management. 2. Aortic stenosis a. The etiology of AS is most commonly congenital (unicuspid or bicuspid aortic valve) or rheumatic disease. b. Mild or moderate AS is usually well tolerated (aortic valve area [AVA] >1.0 cm2). c. If AS is severe, it is preferable to replace the valve before pregnancy. High-risk features include a reduced LVEF and a drop in BP with exercise testing. d. Fetal risks with AS include prematurity, low birth weights, and intrauterine growth restriction. e. For symptomatic patients despite medical therapy, options include balloon valvuloplasty or surgical aortic valve replacement (AVR). Valvuloplasty is preferred owing to a smaller risk of fetal loss (no cardiopulmonary bypass required). f. Patients with bicuspid aortic valves and a dilated ascending aorta (>4.5 cm) should be considered for aortic surgery before pregnancy. However, for patients who are already pregnant, close attention to blood pressure control and monitoring for symptoms are warranted owing to increased risk for aortic dissection and rupture. 3. Mitral regurgitation and aortic regurgitation a. MR etiologies include mitral valve prolapse due to myxomatous disease and rheumatic MR. b. AR is most commonly due to a bicuspid aortic valve, but other etiologies include a history of endocarditis, rheumatic disease, and aortic dilatation. c. These regurgitant lesions typically are well tolerated because systemic vascular resistance is reduced (i.e., reduced afterload) owing to the placental circulation. However, because of increased blood volume, patients can develop pulmonary congestion, which is best treated with diuretics, if needed, and with restriction of activities and decreased sodium intake. Standard heart failure medications including β-blockers and vasodilators can be used. In particular, hydralazine and nitrates are safe for use during pregnancy but should be used with

caution to avoid uteroplacental hypoperfusion. Importantly, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnant women. Vaginal delivery is preferred with severe regurgitant lesions, with epidural anesthesia and a shortened second phase of labor. 4. Right-sided valvular lesions a. Tricuspid regurgitation is usually well tolerated in pregnancy. The exception is Ebstein anomaly associated with an atrial septal defect and Wolff–Parkinson–White syndrome. In this setting, cyanosis may develop owing to shunt reversal, and atrial arrhythmias may occur. b. Pulmonary stenosis (PS) is most often congenital in etiology. It is usually well tolerated in pregnancy, especially when mild or moderate in severity. Balloon valvuloplasty is preferably performed before pregnancy if peak gradient >64 mm Hg. Vaginal delivery is preferred for mild or moderate PS and severe PS with class I or II symptoms. For severe PS with class III or IV symptoms in which percutaneous intervention has failed or could not be done, C-section is preferred. c. Pulmonary regurgitation when severe is an independent predictor of maternal complications, especially if associated with reduced right ventricular function. 5. Mechanical valve prostheses a. Pregnancy is a hypercoagulable state, which increases the risk of thromboembolic events, including valve thrombosis. This risk depends on valve type, position, function, and arrhythmias (atrial fibrillation). Therapeutic anticoagulation during pregnancy is essential for all prostheses, and there are a variety of anticoagulation regimens, which must be individualized for a given patient. These include warfarin, unfractionated heparin, or low-molecular-weight heparin (LMWH). See Table 10.4 for anticoagulant options recommended by the American College of Chest Physicians. b. Warfarin provides the greatest protection against maternal valve thrombosis, thromboembolism, and death when international normalized ratio (INR) is 2.5 to 3.5 throughout pregnancy. Continuous warfarin results in fewer thromboembolic events than heparin in the first trimester followed by warfarin.

c. The risks of warfarin are well established and include increased fetal wastage, congenital fetal anomalies and higher rates of fetal intraventricular hemorrhage, and, most concerning, fetal embryopathy. The risk of fetal embryopathy is dose related, with the greatest risk occurring when warfarin is used at doses >5 mg daily during weeks 6 to 12 of fetal development. d. American and European recommendations regarding anticoagulation in pregnant women with mechanical prostheses are not in agreement. The European Society of Cardiology recommends continued use of warfarin throughout the pregnancy, especially if the dose is 1.5 cm), and critical stenosis (AVA 5%)

Intermediate (cardiac risk LV endocardium and tricuspid valve. Often diagnosed incidentally during transthoracic echocardiography (TTE), it may present with syncope, stroke, or chest pain from prolapse of the tumor into a coronary artery. Although seen with TTE, computed tomography (CT), or magnetic resonance imaging, transesophageal echocardiography (TEE) is the most sensitive modality. Most fibroelastomas do not interfere with valvular function. A TEE performed as part of an evaluation for source of embolus following a stroke may show a fibroelastoma, or on occasion only a remnant stalk may be visualized. Fibroelastomas are usually small (1 cm or those that are mobile with low surgical risk. Surgical resection of tumors typically does not require resection of leaflet tissue (Figs. 10.1 and 10.2).

TABLE 10.7

AHA/ACC Recommendations for Noncardiac Surgery in Patients with VHD

Class IIa

Class IIb

Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AS (level of evidence B)

Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring may be reasonable to perform in asymptomatic patients with severe MS if the valve morphology is not favorable for percutaneous balloon mitral

commissurotomy (level of evidence C) Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with severe MR (level of evidence C)



Moderate-risk elective noncardiac surgery in patients with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AR and a normal LVEF (level of evidence C)



AHA/ACC, American Heart Association/American College of Cardiology; AR, aortic regurgitation; AS, aortic stenosis; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; MS, mitral stenosis; VHD, valvular heart disease. From Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(23):e521–e643.

B. Cardiac myxomas. All myxomas are endocardial based and project into the heart chamber cavity. The majority arise from the left atrial septum (85%); however, they can arise from the right atrial septum (11%) or from a variety of other sites, rarely including a valve. Usually myxomas are single; however, they can be multiple. Myxomas may indirectly affect valvular function by distortion of the supporting apparatus of the valves.

FIGURE 10.1 This is an example of a fibroelastoma on the aortic valve seen by transesophageal echocardiography in the short-axis view. Notice its well-circumscribed appearance, and on moving images it was highly mobile and was attached to the valve by a stalk.

FIGURE 10.2 An example of the same fibroelastoma on the aortic valve seen by transesophageal echocardiography in the midesophageal long-axis view.

KEY PEARLS • Five categories of drugs cause valvular heart disease through activation of the 5hydroxytryptamine 2B serotonin receptor, causing proliferation of myofibroblasts and production of excessive extracellular matrix on valve leaflets. Those classes include migraine drugs (methylsergide and ergotamine), appetite suppressants (fenfluramine and dexfenfluramine), benfluorex, ergot-derived dopaminergic agonists (pergolide and cabergoline), and MDMA (3,4-methylenedioxymethamphetamine). • Patients with valvular heart disease should have a preconception consultation/evaluation regarding risk assessment before becoming pregnant. This assessment should include a careful history and physical, 12-lead ECG, transthoracic echocardiography, and possible stress testing. A level of risk is determined, and discussions regarding risks of therapy and possible complications (maternal and fetal) should be performed by a multidisciplinary team including a cardiologist and an obstetrician/gynecologist. • In general, stenotic lesions are poorly tolerated, whereas regurgitant lesions are better tolerated. This can be explained by the physiologic and hemodynamic changes that occur with pregnancy, labor, and delivery. • Patients at prohibitively high risk (who should be counseled against pregnancy) include

those with severe symptomatic aortic stenosis or mitral stenosis, cardiomyopathy with left ventricular ejection fraction ≤30%, Marfan syndrome with aortic root ≥45 mm, or advanced pulmonary hypertension (two-thirds systemic pressures). • Medications used to treat valvular disease in pregnancy (and postdelivery) must be selected with careful attention to their Food and Drug Administration classification regarding fetal risk (i.e., teratogenicity and more) and whether or not the medication crosses the placenta or passes into breast milk in the postpartum period. • The management of anticoagulation for mechanical valve prostheses in pregnant patients needs to weigh the risks of thromboembolic events in this hypercoagulable state with the risks of teratogenicity and bleeding complications. The exact antithrombotic regimen is tailored to the specific patient’s needs (depending on type and position of prosthesis, any high thrombotic risk features, and dose of anticoagulant needed). • The risk of noncardiac surgery in patients with valvular heart disease is best predicted by the revised cardiac risk index with additional considerations for specific types of valve lesions. High-risk features include high-risk surgery, ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, insulin treatment for diabetes, and a preoperative creatinine of >2 mg/dL, as well as severe symptomatic aortic stenosis (AS); severe asymptomatic AS with left ventricular (LV) dysfunction or an abnormal response to exercise; severe symptomatic aortic insufficiency (AI) or asymptomatic AI with impaired LV function or dilated LV (LV end-systolic diameter >55 mm); severe mitral stenosis (MS) or symptomatic moderate MS, or asymptomatic moderate MS with right ventricular systolic pressure >50 mm Hg; or severe symptomatic mitral regurgitation.

SUGGESTED READINGS Andrejak M, Tribouilloy C. Drug induced valvular heart disease: an update. Arch Cardiovasc Dis. 2013;106(5):333–339. Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines. Chest. 2012;141(2, suppl):e691S–e736S. Burke A, Tavora F. The 2015 WHO classification of tumors of the heart and pericardium. J Thorac Oncol. 2016;11(4):441–452. Diaz Angulo C, Diaz CM, Garcia ER, et al. Imaging findings in cardiac masses: Part I: study protocol and benign tumors. Radiologia. 2015;57(6):480–488. Eagle KA, Brundage BH, Chaitman BR, et al. Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Report of the American College of Cardiology/American Heart Association task force on Practice Guidelines. Circulation. 1996;93(6):1278–1317. Elangbam CS. Drug induced valvulopathy: an update. Toxicol Pathol. 2010;38(6):837–848. Freeman WK, Gibbons RJ. Perioperative cardiovascular assessment of patients undergoing noncardiac surgery. Mayo Clin Proc. 2009;84(1):79–90. Hulselmans M, Vandermeulen E, Herregods MC. Risk assessment in patients with heart valve disease facing non-cardiac surgery. Acta Cardiol. 2009;62(2):151–155. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation, 1999;100:1043–1049. Lung B, Rodes-Cabau J. The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties. Eur Heart J. 2014;(35):2942–2949. Nanna M, Stergiopoulos K. Pregnancy complicated by valvular heart disease: an update. J Am Heart Assoc. 2014;3(3):e000712. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: a report of the American College of Cardiology/American Heart

Association Task Force on Practice Guidelines. Circulation. 2014;129(23):e521–e643. Regitz-Zagrosek V, Lundqvist CB, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology. Eur Heart J. 2011;32(24):3147–3197. Sliwa K, Johnson MR, Zilla P, et al. Management of valvular disease in pregnancy: a global perspective. Eur Heart J. 2015;36(18):1078–1089. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardiothoracic Surgery (EACTS). Eur Heart J. 2012;33(19):2451–2496. Windram JD, Colman JM, Wald RM, et al. Valvular heart disease in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2014;28(4):507–518. Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Practice Guidelines. Chest. 2012;141(2, suppl):e576S–e600S.

Percutaneous strategies for the treatment of mitral valve (MV) stenosis and MV regurgitation are important therapeutic options for selected patients. In the growing field of structural cardiac interventions, the MV presents a new frontier for technologic innovation and less-invasive patient care. In this chapter, we discuss patient selection, technical aspects, and data supporting percutaneous mitral valvotomy, repair, and valve replacement. I.

PERCUTANEOUS MITRAL BALLOON VALVOTOMY A. Introduction. First performed in the mid-1980s, percutaneous mitral balloon valvotomy (PMBV) has now become the preferred method of treating symptomatic patients with severe mitral stenosis (MS) of rheumatic etiology and favorable valve morphology. The procedure entails controlled fracture and separation of fused commissures. Hence, there is no role for PMBV in cases of MS without commissural fusion (e.g., congenital MS or MS secondary to mitral annular calcification) or in cases where the valves are not pliable. Several randomized trials have shown that PMBV offers outcomes that are equivalent to or better than surgical closed or open commissurotomy, with added benefits of lower cost and a minimally invasive approach. Optimal outcomes depend upon accurate assessment of valve anatomy, valve hemodynamics, and patient symptoms. B. Indications 1. The indications for intervention for patients with rheumatic MS are shown in Figure 11.1 and are derived from the 2014 American Heart Association/American College of Cardiology (AHA/ACC)

Guidelines for the Management of Patients with Valvular Heart Disease. In general, there is strong evidence supporting PMBV in patients with reduced exercise capacity and exertional dyspnea in the setting of moderate-to-severe MS and with favorable valve characteristics in the absence of contraindications as detailed later. Weak evidence suggests that the procedure is reasonable for asymptomatic patients with very severe MS (mitral valve area [MVA] ≤1.0 cm2) and may be considered in those with severe MS with MVA ≤1.5 cm2 and systolic pulmonary pressure >50 mm Hg, need for major noncardiac surgery, or new-onset atrial fibrillation, as this represents a high risk of thromboembolism. 2. Although the European Society of Cardiology does not recommend intervention in patients with MVA >1.5 cm2 regardless of the presence of symptoms, the AHA/ACC guidelines state that PMBV may be considered in symptomatic patients with increased transmitral flow velocities, mild-to-moderate left atrial enlargement, and pulmonary capillary wedge pressure >25 mm Hg or mean gradient >15 mm Hg during exercise. Pregnancy also presents unique hemodynamic considerations, and there is a weak level of evidence in support of preconception PMBV for women with asymptomatic MS with MVA ≤1.5 cm2, especially if there is pulmonary hypertension at rest or with exercise. Patients with recurrence of symptomatic MS post-PMBV and with evidence of commissural fusion can also be considered for a repeat intervention if anatomy is favorable.

FIGURE 11.1 Indications for intervention in patients with rheumatic mitral stenosis. LA, left atrium; MR, mitral regurgitation; MVA, mitral valve area; MVR, mitral valve replacement; PCWP, pulmonary capillary wedge pressure; PMBC, percutaneous mitral balloon commissurotomy. (Adapted from Figure 3 in Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63[22]:2438–2488.)

C. Contraindications to PMBV 1. Transesophageal echocardiography (TEE) must be performed before PMBV to accurately assess valve anatomy and most importantly to ensure the absence of left atrial clot and/or moderate-to-severe mitral regurgitation (MR). If thrombus is present and the need for intervention is not urgent, the patient may undergo a trial of therapeutic anticoagulation for 2 to 6 months followed by reassessment with TEE. If thrombus persists or the need for intervention is urgent, a surgical approach is indicated.

2. Several scoring systems have been developed to assess anatomic suitability for PMBV and are discussed later. In order for PMBV to be successful with sustained durability, the valve leaflets and commissures should be relatively noncalcified and pliable with minimal valvular and subvalvular thickening. Heavy calcification of the commissures (especially both commissures) predicts development of postprocedural severe MR; thus, percutaneous valvotomy should be avoided in such patients. Similarly, asymmetric fusion of only one commissure may provide a greater risk for tearing the valve and creating significant MR. Nevertheless, patients with less-than-ideal valve anatomy may still be considered for PMBV if surgery is contraindicated or considered too high risk. Finally, the concomitant presence of MS and severe aortic valve disease, severe tricuspid stenosis or regurgitation, or severe coronary artery disease requiring bypass should prompt consideration of surgical intervention. D. Evaluation 1. Evaluation of the patient begins with careful assessment of symptoms and the degree of functional disability (New York Heart Association [NYHA] class). These include dyspnea with exertion or at rest, cough, hoarseness, hemoptysis, atrial fibrillation, thromboembolism, and right-sided heart failure from elevated pulmonary pressures. For asymptomatic patients or patients with symptoms that seem out of proportion to valve severity, exercise or dobutamine echocardiography can help identify patients with hemodynamically significant disease. 2. A thorough assessment of the valve apparatus using either transthoracic echocardiography (TTE) or TEE is imperative to determine suitability and likelihood of success (and complications) of PMBV. This can be accomplished through several scoring systems, the most common of which is shown in Table 11.1 (Wilkins score). Of note, none of the scoring systems are perfectly reproducible and the Wilkins score omits commissural calcification. Thus, even patients deemed to have an ideal Wilkins score may experience suboptimal outcomes, including the development of severe MR. The commissural calcification scoring system shown in Table 11.2 can be used adjunctively to further predict the development of severe MR. In patients with an echo score that is favorable (i.e., ≤8 by Wilkins score), a commissural

calcification score 22 predicts a smaller increase in valve area and reduced success rate of achieving a final valve area >1.5 cm2 without MR. Cardiac catheterization with direct measurement of valve gradients has largely been supplanted by echocardiography and is only necessary when there is conflicting information derived from noninvasive studies.

Wilkins Echocardiographic Scoring System of the Mitral Valve Component Grade

Leaflet Mobility

Valvular Thickening

Subvalvular Thickening

1

Highly mobile,

Near normal (4—5

Minima

restricted only

at tips 2

Base and midportion have reduced mobility

mm)

Mid-leaflet thickening, marke

'

Valvular Calcification

% Single area of

,

rdae up to ne-third of length

brightness

Scattered areas of brightness restricted to leaflet margins

eal‘o,

3

Forward during En ' diastole, mainly

u (5—8

at base 4

No or minin®

forward mov d ia

le

rked leaflet

thickening (>8— 10 mm)

Thickening extending to distal one-third

Brightness extending to mid-portion of

Extensive

Extensive

thickening and shortening of all chordae down to papillary muscle

leaflets

brightness through most of the leaflet tissue

NOTE: Total score is calculated by adding each component score; 1 cm2/m2 of the body surface area, if there is complete opening of at least one commissure, or if there is worsening of MR by more than one grade. Greater caution is taken in patients older than age 65 or pregnant patients. Good immediate results are defined as final valve area >1.5 cm2 and an increase of at least 25% of valve area, or final valve area >1.5 cm2 with less than moderate MR.

FIGURE 11.2 Key steps in percutaneous mitral balloon valvotomy. A: Left ventriculography is performed to establish the plane of the mitral valve and assess the degree of mitral regurgitation. B: Transseptal puncture is then performed (arrowheads). C: The deflated Inoue balloon is then passed through the atrial septum into the left atrium (arrows). D: The distal portion of the balloon is inflated with a few milliliters of diluted contrast. E: The mitral valve is crossed. The distal portion of the balloon is further inflated and then pulled back into the mitral orifice. F: The proximal and central portions are finally inflated.

F. Periprocedural management. All patients who have undergone PMBV should be admitted to the hospital and monitored for complications. Approximately 24 to 48 hours after the procedure, repeat TTE is indicated to assess valve area and the degree of MR. If MR appears to be significantly worsened, TEE can be performed to determine the mechanism and further assess severity and need for valve surgery. G. Complications. Rates of various complications from PMBV are fairly low and are dependent upon a variety of factors including operator experience, technique employed, patient clinical profile, and valve characteristics. In-hospital death is rare (8), greater valve calcification, higher postprocedural pulmonary artery pressure, preprocedural MR that is ≥2+, postprocedural MR that is ≥3+, severe tricuspid regurgitation, and final valve area. Recurrence of stenosis (loss of more than 50% of the initial gain with an MVA 50 mm Hg if the likelihood of successful repair is >95% and the expected

mortality is 1 year). Such patients are typically too frail for surgery, are of advanced age (>75), and have an elevated predicted operative mortality risk typically ≥6% to 8%, hostile chest, severe pulmonary hypertension, or extensively calcified ascending aorta. 2. Functional MR: All recommendations from major societies regarding surgical intervention for severe secondary, or functional, MR (FMR) are based on limited evidence. Although effectiveness has not been established, isolated MV surgery may be considered in those with severe FMR if symptoms persist despite optimal medical therapy (including resynchronization therapy) or with no options for revascularization. Survival after surgery for FMR is generally poor and recurrence is common, which provides the rationale for a less-invasive percutaneous option. Despite a large worldwide experience in this group of patients, the MitraClip system is not approved for this application in the United States. Two large prospective trials (COAPT and RESHAPE-HF) are currently underway to assess the utility of the clip in this patient population. B. Contraindications. Implantation of the MitraClip requires transseptal catheterization to access the left atrium and MV. The presence of left atrial thrombus, vegetation, deep venous thrombus, or a bleeding disorder is a contraindication to the procedure. Additional contraindications include active endocarditis and rheumatic valve disease. The EVEREST trial also excluded patients with acute myocardial infarction in the preceding 12 weeks, ejection fraction 55 mm, severe mitral annular calcification, and valvular anatomy that may preclude safe and proper clip deployment. The clip was also not evaluated in patients with a history of prior MV surgery or valvuloplasty. C. Evaluation. Evaluation of the patient begins with careful assessment of symptoms and the degree of functional disability (NYHA class). In most cases, TTE provides adequate evaluation of left ventricular dimensions, pulmonary pressures, and the mechanism and severity of MR. Operative mortality for surgical MV repair or replacement should be estimated with the Society of Thoracic Surgeons (STS) risk

calculator. Additional predictors of poor surgical outcome should be identified (frailty, inability to tolerate cardiopulmonary bypass, hostile chest, advanced cirrhosis), and the decision to defer surgical intervention should be made in conjunction with an experienced surgeon. Optimal results are obtained when the primary regurgitant jet originates from malcoaptation of the A2 and P2 scallops, with a flail width 300 seconds. The TAVR sheath should be upsized over a stiff wire; we prefer the Lunderquist (Cook Medical, Bloomington, IN). The AV is then crossed; in our practice, this is most often performed using an Amplatz Left 1 (AL 1) catheter and a 0.035" straight-tip guidewire. Once the valve is crossed, the guidewire of choice for TAVR device delivery is positioned in the LV with the belly of the wire in the LV apex. For wires without a preformed LV loop, care should be taken to create a gentle curve that can be placed in the LV apex. For balloon-expandable devices, we prefer the Amplatz Extra Stiff 0.035" guidewire (Cook Medical, Bloomington, IN), and for selfexpandable devices that require slightly more support we use the Amplatz Super Stiff guidewire (Boston Scientific, Natik, MA). F. The next step prior to placing the new valve is often BAV. This was once thought to be an essential component of all procedures but is now being performed with decreasing frequency prior to balloonexpandable valve implantation and is rarely required for selfexpandable valves. In some valves that are very severely calcified, however, it may be difficult to pass the TAVR device without predilation. Furthermore, predilation may assist with the ultimate expansion of the prosthesis and reduce the incidence of PVL. Drawbacks, however, include the added opportunity for liberation of embolic particles that could lead to neurologic events, and the potential for inducing acute severe AR, which may be poorly tolerated during the time interval required to subsequently implant the valve. G. When ready, the valve is loaded onto the delivery device and advanced into position in the aortic annulus. The correct position can be confirmed by contrast injection through the pigtail catheter in the noncoronary cusp, usually using a right anterior oblique caudal or left anterior oblique cranial projection. The balloon-expandable valves are typically positioned with the lower 20% of the device in the aortic

annulus and the remainder of the scaffolding above the valve level (Fig. 12.3). For the self-expandable valves, the distal portion of the device can be partially unsheathed in the LV outflow tract (LVOT) and withdrawn if needed to the appropriate height (Fig. 12.4). When fully expanded, the CoreValve will be anchored in the proximal aorta above the sinus of Valsalva, so the scaffolding will extend beyond the coronary ostia by design, but this does not impede coronary blood flow or prevent subsequent angiography. Rapid pacing at a heart rate of 180 to 220 bpm is initiated prior to inflation of the balloon-expandable valve in order to temporarily reduce cardiac output. Pacing should not be suspended until the balloon is deflated to prevent the balloon from being ejected and dislodging the valve. When placing a self-expanding valve, RV pacing is not required, but sometimes a more modest rate of 100 to 110 bpm is used to reduce cardiac output slightly while the valve is unsheathed.

FIGURE 12.3 Deployment of the Edwards SAPIEN 3 valve under rapid pacing (A, B, C) and confirmation of appropriate placement and lack of significant aortic regurgitation (D). Images taken at RAO 34 CAUD 31. TEE, transesophageal echocardiography.

H. Once the valve is implanted, it should be investigated for appropriate position and function using angiography, hemodynamic measurements, and echocardiography when available. When TEE is not utilized, aortic root angiography or transthoracic echocardiography should be done to exclude AR (Figs. 12.3 and 12.4). A wide pulse pressure and low aortic diastolic pressure can also be clues to significant AR. It is

very important to identify AR owing to its association with poor outcomes, and attempts should be made to reduce moderate or severe AR when possible. When regurgitation is paravalvular, subsequent balloon postdilation or placement of a second valve can sometimes reduce the degree of regurgitation, but overexpansion of the scaffolding can at times lead to central regurgitation, which can only be addressed by placement of a second valve. In certain situations, percutaneous PVL closure may be necessary to adequately address the AR. I. The final step in TF-TAVR is removal of the access sheaths and securing of the preclosure sutures. In the absence of contraindications, protamine can be safely given in most cases to reverse the effects of heparin prior to sheath removal. It is important to maintain wire access to the femoral artery during this process in the event of a failed suture or a need to reestablish access to manage vascular complications. A final iliac angiogram taken through the contralateral femoral arterial sheath can be helpful to exclude occult hemorrhage or other vessel dissection and, when needed, proximal balloon occlusion/dilation or placement of a stent can be performed from this contralateral access.

FIGURE 12.4 Deployment of the self-expanding Medtronic CoreValve Evolut R (A, B, C) and confirmation of appropriate placement and lack of significant aortic regurgitation (D). Images taken at RAO 28 CAUD 36. TEE, transesophageal echocardiography.

VI.

ALTERNATIVE ACCESS When femoral arterial access is not possible, alternative access approaches must be used. TA access can be obtained through a small left anterior intercostal thoracotomy. Pledgeted sutures are secured to a nonfatty portion of the left ventricular apex and needle access, and sheath

placement proceeds through the presutured myocardium. We prefer crossing the valve using a balloon-tipped Arrow-Berman catheter (Teleflex, Morrisville, NC) with a 0.035" wire lumen to minimize the risk of passage through the mitral valve chords, and ultimately a stiff wire is advanced to the descending aorta. The valve is then crimped onto the delivery balloon in the opposite orientation, and is advanced through the LV apex to the LVOT. Valve placement proceeds with similar steps including rapid RV pacing, and ultimately the apex and thoracotomy are surgically closed. TAo-TAVR involves a partial sternotomy, right thoracotomy, or manubriotomy to obtain direct visualization of the ascending aorta. This facilitates the placement of the delivery sheath directly into the aorta. The steps for TAVR then follow just as they would for TF-TAVR with retrograde crossing of the AV and delivery of the prosthesis under rapid pacing. TAo-TAVR differs importantly from a miniAVR in that although the surgical access is similar, it does not require cardiopulmonary bypass and is completed without arresting the heart. VII.

PERIPROCEDURAL/PERIOPERATIVE MANAGEMENT A. It is important to optimize renal function, respiratory status, and hemodynamic status prior to TAVR. In some patients who are especially tenuous, hospitalization prior to TAVR to ensure optimal volume status can be helpful. Just as with any surgical valve replacement, patients should be free of infection prior to valve implantation, and any active bleeding should be investigated, despite the fact that TAVR does not require the very high levels of heparinization that are typical for surgical procedures that involve cardiopulmonary bypass. B. After the procedure, it is important to remain vigilant in monitoring for potential complications that may require timely intervention. Special attention should be focused on assessing for bleeding complications, hemodynamic instability, and conduction abnormalities. Although initially all patients at our institution were managed in the cardiovascular intensive care unit for the first evening after TAVR, as the incidence of procedural complications and overall experience with the procedure have improved, we now manage most patients in a postanesthesia care unit prior to transfer to the regular nursing floor. C. Adjunct therapy 1. Pharmacologic management of patients during TAVR has been largely extrapolated based on the surgical and PCI literature. There

are unfortunately no large studies comparing different antiplatelet or anticoagulant strategies for use during TAVR. Generally speaking, intraprocedural anticoagulation is initiated after obtaining arterial access and safely positioning the temporary pacing wire, with a goal of achieving an ACT > 300 seconds. The BRAVO 1 trial showed lower rates of in-hospital major bleeding and similar rates of ischemic stroke in patients who underwent elective BAV with bivalirudin as compared to heparin, and the BRAVO 2/3 trial is a similar trial that is under way for patients undergoing TAVR. However, because of the risk of major bleeding complications during the procedure, we prefer to use heparin as a reversible agent during TAVR. 2. Postprocedurally, there is similarly a lack of evidence to support any specific pharmacologic strategy. Even the surgical literature is controversial regarding the use of warfarin after SAVR with a bioprosthetic valve, and although some surgeons advocate for 3 months of oral vitamin K antagonist therapy, the 2012 American College of Clinical Pharmacology guidelines recommend aspirin alone. The 2012 American College of Cardiology Foundation/American Association for Thoracic Surgery/Society for Cardiovascular Angiography and Interventions/Society of Thoracic Surgeons (ACCF/AATS/SCAI/STS) guidelines for TAVR recommend aspirin (50 to 100 mg daily) plus clopidogrel (75 mg daily) for 3 months after TAVR followed by aspirin alone (grade 2C). The ARTE trial is ongoing and aims to study aspirin alone vs. aspirin plus clopidogrel after TAVR, and the AUREA trial is comparing dual antiplatelet therapy to the oral vitamin K antagonist acenocoumarol. Importantly, post-TAVR atrial fibrillation is associated with higher risk of late neurologic events, and appropriate anticoagulation is necessary in that setting. For those patients, use of therapeutic anticoagulation with a single antiplatelet agent may be reasonable. For patients unable to tolerate anticoagulation, consideration may be given to percutaneous left atrial appendage occlusion. VIII. COMPLICATIONS As valve design and delivery sheath technology have advanced, the overall incidence of TAVR-related complications has consistently decreased. Nevertheless, there are several important procedural

complications that must be considered in patients undergoing TAVR that can lead to significant morbidity, mortality, and added hospital costs (Table 12.2). Although the early TAVR literature was somewhat inconsistent in the definitions of complications, the Valve Academic Research Consortium (VARC-2) has since outlined standardized criteria that are used in both clinical practice and clinical trials. A. PVL has been significantly more common in patients who undergo TAVR compared with SAVR. This is not surprising considering that the valve must be expanded inside of a native annulus that is often heavily calcified and asymmetric. What has been surprising though is the strong association between modest degrees of AR and significantly worse outcomes in major clinical trials involving early-generation devices. Even mild PVL has been shown to be a risk factor for mortality after TAVR in some studies. For this reason, many of the technologic advances in newer-generation TAVR devices have been focused on reducing PVL. One example is the Direct Flow valve, which is built with two inflatable cuffs on the superior and inferior valve apparatus, designed to create a tight seal between the cylindrical valve and the asymmetric annulus. Another example is the Edwards S3 valve, which is constructed with a skirt on the external portion of the lower portion of the valve stent and is designed to create a seal between the stent and the annulus. With these innovations, more contemporary trials have shown significant reductions in PVL. TABLE 12.2

Potential Complications Associated with Transcatheter Aortic Valve Replacement (TAVR) Ways to Mitigate or Manage the Complication

Complication

Risk Factors

Aortic regurgitation

• Asymmetric or severely • Annular sizing and valve calcified annulus. measurement by computed tomography, cardiac magnetic • Device undersizing. resonance imaging, or 3D • Device malpositioning transesophageal echocardiogram (too high or too low in the rather than single-dimension sizing left ventricular outflow by 2D transthoracic tract). echocardiogram. • Postdilation or placement of a second valve (must be weighed against risk of stroke or annular rupture).

Central regurgitation usually • requires placement of a second valve. Stroke

• Older age, female, prior cerebrovascular or peripheral vascular disease, diabetes, hypertension, prior cardiac surgery. • Need for balloon postdilation. • No clear differences in TAVR route or device design. • Post-TAVR atrial fibrillation.

• Appropriate heparinization during procedure. • Appropriate pharmacologic treatment postprocedure. • Anticoagulation when needed for atrial fibrillation. • Minimize unnecessary manipulations of the device in the aortic root. • Cerebral embolic protection devices (under investigation). • Alternative antiplatelet and anticoagulant regimens (under investigation).

Vascular complications

• Small femoral artery luminal diameter. • Calcified arteries, especially circumferential.

• Careful preprocedural planning and evaluation of arterial access. • Confirm correct femoral artery placement (above bifurcation, below inferior epigastric) prior to large sheath dilation. • Preclosure of the arteriotomy site. • Iliac angiography at conclusion of the case. • Prompt endovascular or surgical repair of vascular injuries.

Conduction system disease • Preexisting conduction • Consider active fixation, temporary system disease. pacemaker for high-risk cases and for self-expandable devices. • Preexisting right bundle branch block. • Carefully monitor patients postprocedure for conduction • Valve oversizing. system disease. • Low valve implantation. • Permanent pacemaker • Self-expandable devices. implantation when indicated. • Calcified annulus. • Limit device oversizing (must be weighed against risk of paravalvular regurgitation). Cardiac tamponade

• Temporary pacemaker perforation. • Guidewire perforation. • Annular rupture during balloon aortic valvuloplasty or valve deployment (more common in oversized

• Careful wire management. • Limit device oversizing (must be weighed against risk of paravalvular regurgitation). • Prompt diagnosis and management in the setting of hemodynamic instability.

valves, calcified annulus, Consider self-expanding device with postdilation, and • (less risk of annular rupture) for with balloon-expandable severely calcified annulus. valves).

B. Given the strong associations between AR and outcomes after TAVR, it is important to evaluate for significant regurgitation at the time of valve placement. This is most commonly done with hemodynamics, TTE, TEE, and/or aortic root angiography. Usually, multiple points of data are taken together to provide a thorough understanding. When significant PVL is identified, valve postdilation can sometimes create a tighter seal and reduce the severity of AR. Another strategy that has been used is to place a second percutaneous valve within the first valve, which is particularly useful if the regurgitation is due to leaflet malfunction or to malpositioning of the initial valve. A valve that is placed too high in the annulus can sometimes leak around the inferior border, and this usually requires a second valve to be placed just inferior to the first. The drawback to postdilation or placement of an additional valve is that it places the patient at slightly higher risk for other complications including embolic stroke, annular rupture, and conduction abnormalities. Finally, in select cases, if AR cannot be reduced by traditional means, percutaneous PVL closure should be performed. C. Stroke is a dreaded complication of any cardiovascular procedure. Most strokes associated with TAVR are thought to be embolic in nature but may also rarely be related to global hypoperfusion or hemorrhagic complications. The results of the first randomized controlled trial of the Edwards SAPIEN valve (PARTNER IA and IB) raised initial concerns for an increased risk of stroke with TAVR as compared to medical management or SAVR, with rates at 30 days as high as 6.7% in patients at extreme surgical risk. However, recent analyses of this patient group have shown that the rate of stroke with TAVR is significantly lower than initially thought, and that there is no increased risk as compared to surgery over the long term. One large meta-analysis of 10,037 patients undergoing TAVR documented the rate of stroke at 30 days to be 3.3 ± 1.8%. The recently presented results from the PARTNER II trial of the SAPIEN 3 valve showed a 1.5% rate of stroke in the high-risk cohort and 2.6% in the intermediate cohort at 30 days.

1. Despite the declining rates of clinical stroke associated with TAVR, studies utilizing diffusion-weighted MRI have shown a high incidence of subclinical findings in both surgical and transcatheter patients, so there remains an intense focus on reducing the incidence of embolic events during TAVR. There are a number of embolic protection devices that have been studied for use during TF-TAVR, and one filter device that has been used in transaortic TAVR. Thus far, early studies of these devices have shown a reduction in the overall volume of new lesions detected by MRI, but no reduction in clinically apparent events. Several larger trials are ongoing. Finally, several investigations are ongoing to study the optimal anticoagulation and antiplatelet regimen to reduce thromboembolic events during TAVR. D. Vascular complications are among the most common procedure-related complications during TAVR owing to the relatively large sheaths that are required. Fortunately, as device technology has progressed, the size of the sheaths that are required has improved dramatically from #22 French to #24 French for the first-generation SAPIEN valve, to #16 French to #18 French for the SAPIEN-XT and CoreValve, to #14 French for the SAPIEN3 and Evolut R systems. Thus, although the rate of major vascular complications has been reported to be as high as 16% in some early trials, the incidence was lower than 6% among patients in the PARTNER II trial using the S3 valve. 1. Vascular complications can be as modest as VARC-2 minor bleeding, or as serious as rupture, dissection, or occlusion. Minor bleeding can usually be resolved with simple external pressure, but more serious complications may require urgent endovascular repair. For this reason, it is helpful to maintain contralateral femoral arterial access until hemostasis is achieved and the preclosure sutures have been successfully secured after valve delivery-sheath removal. This facilitates the rapid utilization of endovascular ballooning or even covered stent placement when necessary. Operators should be proficient in peripheral vascular intervention (or have ready access to peripheral vascular specialists) in order to maintain the safety of TAVR procedures. E. Late bleeding complications are more commonly a result of gastrointestinal complications, neurologic complications, or traumatic falls and are more common in patients with atrial fibrillation requiring systemic anticoagulation. In the PARTNER cohort/registries, late

bleeding complications occurred with an incidence of 5.9% at a median of 132 days after TAVR. F. Conduction system disturbances are another potential complication after TAVR, likely due to mechanical compression of the His bundle fibers as they pass near the septal wall of the LVOT. Patients with a preexisting RBBB are at especially high risk for developing complete heart block after TAVR, as the left-sided fibers are most vulnerable to compression during the procedure. Other risk factors for developing heart block include lower implantation of the prosthesis, a calcified annulus, or a significantly oversized valve. Also, there appears to be a significantly higher risk of requiring a pacemaker after TAVR in patients who receive a self-expanding valve as compared to the balloon-expandable valves. In the GARY registry, the rate of permanent pacemaker implantation after TAVR was 25.2% with the Medtronic CoreValve and 5.0% with the Edwards SAPIEN device. Thus, it is reasonable to maintain an active fixation temporary pacemaker device for 72 hours after placement of the CoreValve to ensure adequate native conduction. G. Annular rupture and cardiac tamponade are very rare but serious complications associated with TAVR. Annular rupture has been reported in up to 1% of procedures and may occur at any level of the annulus and aortic root. Annular rupture seems to be most closely associated with balloon inflation, so is exceedingly rare with selfexpanding devices unless postdilation is needed. Factors that seem to be associated with annular rupture include oversizing of the valve prosthesis by more than 20% and severe LVOT calcification. Annular rupture may range in clinical presentation from asymptomatic and contained to the rapid development of hemopericardium and cardiovascular collapse. The presence of hemopericardium and tamponade should always raise suspicion for annular rupture but can also be a result of trauma from either the temporary pacemaker wire in the right ventricle or the curved support wires in the left ventricular apex. The key to management of cardiac tamponade is rapid identification and treatment. Less severe situations can often be managed conservatively with reversal of procedural anticoagulation or with pericardial drainage alone, though some cases will require emergent cardiopulmonary bypass and surgical correction. H. Coronary artery obstruction is a rare but potentially avoidable complication of TAVR. In the published literature, it occurs in 0.4% to

1.3% of procedures and should be suspected in the following situations: when the coronary ostia have a low height from the aortic annulus; when there is significant sinotubular effacement; when there is a large septal bulge, which can lead to valve orientation tilted toward the left main ostium; or with a heavily calcified native valve leaflet tip. Of all these factors, the most important may be to understand the relationship between coronary ostium height, coronary sinus depth, and corresponding leaflet length. Patients with a low coronary ostium in the presence of a relatively long leaflet and shallow cusp with sinotubular effacement are at especially high risk for occlusion after valve implantation. The best way to evaluate for this potential complication is by gated cardiac computed tomography angiography (CTA) with contrast. Rarely, this may lead to a decision to avoid TAVR in favor of a surgical valve replacement. There are ways to mitigate the risk of coronary artery obstruction in carefully selected difficult cases. The primary strategy is to protect the coronary ostium by placing a wire, a balloon, or even an undeployed stent into the coronary artery prior to valve implantation. For this reason, we favor a balloon-expandable valve, which allows the operator to maintain access to the coronary artery above the frame of the valve stent. Selfexpanding valves by design rest on the proximal ascending aorta covering the sinus, complicating subsequent coronary interventions, which must be completed through the side struts of the valve frame. IX.

OUTCOMES (SHORT TERM, LONG TERM) There are several pivotal, randomized trials of TAVR that have formed the basis for approval of the technology by the US FDA and serve as the best representation of short- and long-term outcomes after TAVR. The PARTNER trial randomized 699 patients with severe AS who were considered at high surgical risk (cohort A) to TAVR vs. SAVR, and 358 patients with severe AS who were not candidates for surgical AVR (cohort B) to TAVR vs. medical therapy including BAV. Among the inoperable patients, at 1 year, there was 30.7% overall mortality in the TAVR arm as compared to 50.7% mortality in the patients randomized to usual care. In cohort A, there was similar mortality at 1 year with TAVR (24.3%) as compared to SAVR (26.8%), a finding that has now been consistent up to 5 years of follow-up. In this study, which involved the first-generation SAPIEN valve, there was less major bleeding with TAVR but more vascular complications and a higher incidence of paravalvular AR. The

initial 1-year outcomes demonstrated a higher risk of the composite of all neurologic events compared to surgical AVR, though subsequent analyses have demonstrated equivalence in the two groups. Subsequently, the Medtronic CoreValve was studied in the US CoreValve Pivotal trial among 489 patients with severe AS who were deemed to be at extreme surgical risk and demonstrated 24.3% all-cause mortality at 1 year. Among 647 patients at high surgical risk who were randomized to TAVR vs. SAVR, there was 14.2% mortality at 1 year with TAVR vs. 19.1% with SAVR (p = 0.04 for superiority of TAVR), and no increased risk of stroke with TAVR. It should be cautioned that because of significant differences in patient characteristics, comparisons cannot be made between the safety and efficacy of the balloon-expandable SAPIEN valves and the self-expanding CoreValve on the basis of these trials. Most recently presented were the 30-day outcomes from the PARTNER II trial involving high- and intermediate-risk patients treated with the Edwards SAPIEN 3 valve. Among 583 high-risk patients with mean age of 82.6 years and mean STS score of 8.6%, there was 2.2% mortality at 30 days with a 1.5% rate of stroke. Among the 1,076 intermediate-risk patients of mean age 81.9 years and mean STS score of 5.3%, there was 1.1% mortality at 30 days and a 2.6% rate of stroke. Looking at the high- and intermediate-risk patients together, there was only a 3.7% rate of moderate AR and 0.1% rate of severe AR, which had been one of the major issues with the earlier-generation devices. Data at 2 years have now been reported from PARTNER IIA, which randomized 2,032 intermediate-risk patients to TAVR vs. SAVR and showed no difference in all-cause mortality or disabling stroke (HR 0.89 for TAVR; 95% CI 0.73-1.09; p = 0.25). The third-generation Edwards S3 valve was also studied in 1,077 intermediate-risk patients, and this trial demonstrated noninferiority as well as superiority for the composite end point of allcause mortality, stroke, and moderate or severe AR as compared to a contemporary, propensity-matched cohort of patients undergoing SAVR from the PARTNER IIA trial. Finally, we have data from the Valve-in-Valve (ViV) International Data Registry, which included 459 patients who were enrolled from 55 centers across Europe, North America, Australia, New Zealand, and the Middle East between 2007 and 2013. Patients had a mean age of 77.6 (+/− 9.8) years, were 56% male, had an average STS score of 9.8% (interquartile range, 7.7% to 16.0%), and required a valve procedure owing to isolated bioprosthetic stenosis in 39.4% of cases, isolated regurgitation in 30.3% of

cases, and combined degeneration in 30.3%. Overall 30-day mortality was 7.6% with a 1.7% incidence of major stroke, and survival to 1 year was 83.2%. Patients with isolated bioprosthetic stenosis and those with a small bioprosthetic valve size pre-TAVR were at significantly higher risk for 1year mortality after ViV TAVR. Implanted devices included both balloonexpandable (53.6%) and self-expandable (46.4%) valves. X.

CONCLUSION. In summary, the evidence demonstrates that TAVR is an accepted treatment for patients with severe AS who are at prohibitive surgical risk, and is an effective alternative to surgical AVR for patients at intermediate or high surgical risk. Furthermore, the use of ViV TAVR for degenerated bioprosthetic valves appears to be a promising strategy to avoid reoperation among patients at high risk for surgical complications, and as an only option for appropriately selected patients who are considered inoperable. Randomized trials of TAVR vs. SAVR involving low-risk patients are ongoing.

KEY PEARLS • Transcatheter aortic valve replacement (TAVR) has become an established therapy for patients with severe aortic valve stenosis who are not candidates for surgery, and is an accepted alternative for patients at intermediate or high surgical risk. Trials in low-risk populations are ongoing. • TAVR has shown excellent safety and has grown from a technologic standpoint to include multiple valve designs and vascular access approaches. • Evaluating a patient for TAVR requires a heart-team approach, which is a multidisciplinary assessment of each patient with the collaboration of cardiac surgeons, interventional cardiologists, imaging specialists, other experts from different disciplines, nurses, and other support staff. • The preferred route for TAVR is via transfemoral access, but in patients without appropriate iliofemoral vessels, alternative access must be considered, the most common of which are the subclavian, transapical, or transaortic approaches. • Other vascular approaches that have been used include axillary artery, carotid artery, and finally venous options including trans-septal and transcaval access. • In establishing candidacy for TAVR and planning for appropriate access, it is important to have high-quality imaging of the iliofemoral arteries and the aortic annulus, both of which can typically be evaluated by a gated CT scan with contrast. • Complications that are particularly important to consider in patients undergoing TAVR include paravalvular AR, stroke, vascular and access site complications, bleeding, conduction system disease, cardiac tamponade, and annular rupture.

SUGGESTED READINGS Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med. 2014;370:1790–1798. Athappan G, Patvardhan E, Tuzcu EM, et al. Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: meta-analysis and systematic review of literature. J Am Coll Cardiol. 2013;61:1585–1595. Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation. 2002;106:3006–3008. Dvir D, Webb JG, Bleiziffer S, et al. Transcatheter aortic valve implantation in failed bioprosthetic surgical valves. JAMA. 2014;312:162–170. Genereux P, Head SJ, Van Mieghem NM, et al. Clinical outcomes after transcatheter aortic valve replacement using valve academic research consortium definitions: a weighted meta-analysis of 3,519 patients from 16 studies. J Am Coll Cardiol. 2012;59:2317–2326. Holmes DR Jr, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol. 2012;59:1200–1254. Kappetein AP, Head SJ, Genereux P, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the valve academic research consortium-2 consensus document. J Am Coll Cardiol. 2012;60:1438–1454. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597–1607. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediaterisk patients. N Engl J Med. 2016;374(17):1609–1620. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521–e643. Piazza N, Kalesan B, van Mieghem N, et al. A 3-center comparison of 1-year mortality outcomes between transcatheter aortic valve implantation and surgical aortic valve replacement on the basis of propensity score matching among intermediate-risk surgical patients. JACC Cardiovasc Interv. 2013;6:443–451. Popma JJ, Adams DH, Reardon MJ, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol. 2014;63:1972–1981. Ross J Jr, Braunwald E. Aortic stenosis. Circulation. 1968;38:61–67. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187–2198. Thourani VH, Kodali S, Makkar RR, et al. Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis. Lancet. 2016;387(10034):2218– 2225. Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines. Chest. 2012;141:e576S–e600S.

I.

INTRODUCTION The era of percutaneous valve procedures in the pediatric population was ushered in by the first in-man transcatheter implantation of a pulmonary valve in a 12-year-old patient with tetralogy of Fallot (TOF) and a dysfunctional right ventricle (RV) to pulmonary artery (PA) conduit, reported by Bonhoeffer et al. in 2000. The device utilized in that procedure was a bovine jugular venous valve sewn to an expandable stent. After several modifications, the device was marketed as the Melody valve (Medtronic Inc., Minneapolis, MN) (Fig. 13.1), was approved by the Food and Drug Administration (FDA) initially under Humanitarian Device Exemption guidelines in 2010, and received premarket FDA approval in 2015. At the time of this writing, there are two valves approved by the FDA for transcatheter pulmonary valve replacement (percutaneous pulmonary valve replacement [PPVR]), the Melody valve and the Edwards SAPIEN XT valve (Edwards Lifesciences, Irvine, CA), both specifically approved for patients with dysfunctional RV to PA conduits. Approximately 20% of patients with congenital heart disease have a lesion affecting the RV outflow tract (RVOT), and a subset of these patients require a surgically implanted conduit, often early in childhood. These conduits have a limited life span, either because of somatic growth of the patient or, in fully grown patients, because of acquired stenosis or regurgitation of the valved conduit. The availability of a percutaneous approach will serve to decrease the number of open heart procedures these patients will face over the course of their lifetime, and is one of the most exciting developments in the field of pediatric cardiac intervention in the past decade.

II.

INDICATIONS The majority of patients who undergo PPVR at this time have had surgical placement of an RV to PA conduit to treat their underlying congenital heart disease, most commonly TOF and, in smaller numbers, other conotruncal defects such as truncus arteriosus. Another important group of patients benefiting from this technology includes those who have had a Ross procedure to treat their aortic valve disease and are also at risk of developing RV to PA conduit dysfunction. Although approval of the Melody valve was predicated on placement within an existing RV to PA conduit, its use has been extended to patients with dysfunctional bioprosthetic and also native pulmonary valves, provided the dimensions of the RVOT do not exceed the limit required for stable implantation of the valve. Implantation in a native RVOT requires creation of a “landing zone” by placement of one or more stents (“prestenting”); the valve is then deployed within the stented region. Whether the valve is deployed within a previously existing conduit or a stented native RVOT, the indications for intervention are pulmonary stenosis (PS), pulmonary regurgitation (PR), or a combination of both. A. Pulmonary stenosis. PPVR is recommended when the RV systolic pressure is ≥75 mm Hg, or RV:left ventricular (LV) systolic pressure ratio is >0.7, but may be considered at lower pressures if RV function is diminished. Generally, this corresponds to a peak instantaneous gradient of ≥50 to 60 mm Hg, and mean gradient of ≥35 mm Hg by echocardiogram.

FIGURE 13.1 The Melody valve is a bovine jugular venous valve sewn to an expandable platinum–iridium stent. Note the blue sutures on one rim of the valve to ensure it is mounted correctly, with the leaflets opening toward the main pulmonary artery. With permission, Medtronic Inc., Minneapolis, MN.

B. Pulmonary regurgitation. Indications for PPVR for PR are less well defined than for PS and are in fact evolving in part owing to availability of a less invasive option than surgical replacement. The following considerations have moved the pendulum toward earlier replacement than previously recommended: 1. Using an RV end-diastolic volume of ≥170 mL/m2, previously the threshold to recommend surgical PVR, RV size does not return to normal following PVR in the majority of patients. 2. RV function is considered normal if RV ejection fraction (RVEF) is ≥45% measured by cardiac MRI. When RV dysfunction is already present at the time of PVR in patients with predominant PR (in contrast to PS) despite evidence of symptomatic improvement and

decreased RV volumes after PVR, RVEF frequently remains unchanged. 3. The detrimental effects of chronic PR and irreversible injury to the RV must be weighed against the risk of multiple operations, and the lack of clear evidence to date that PVR improves arrhythmia burden or survival. With a percutaneous alternative, the threshold for intervention might be justifiably lower. 4. Taking the above-mentioned considerations into account, and adapting Geva’s recommendations for surgical PVR to percutaneous PVR, PPVR should be recommended when there is moderate to severe PR (≥25% regurgitant fraction) and: a. Symptoms, including right heart failure or progressive decrease in exercise tolerance or functional class, or: b. No symptoms and at least two of the following: i. RV end-diastolic volume index >150 mL/m2 ii. RV end-systolic volume >80 mL/m2 iii. RVEF 60% and LVESD 95% with an expected mortality rate of 50 mm Hg).

B

Concomitant mitral valve repair is reasonable in patients with chronic moderate

C

primary MR undergoing cardiac surgery for other indications. Class IIb Mitral valve surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF 90% at 10 years compared with 60% for functional or rheumatic disease. Postoperative survival is excellent with 30-day mortality of 1% or less for the treatment of degenerative disease in experienced centers; if the etiology is functional MR, early mortality approaches 5%. Mortality for isolated mitral valve replacement is slightly increased compared with repair. In-hospital mortality has been reported to range from 5% to 9% in recent analyses of large administrative databases. Bioprosthetic valves degenerate over time, and at 15 years there will be structural failure in approximately 50% of surviving patients. Mechanical valves are resistant to degeneration, but carry with them bleeding risks associated with therapeutic anticoagulation. II.

THE TRICUSPID VALVE A. Introduction. The tricuspid valve apparatus is composed of the tricuspid annulus, chordae tendinae, and papillary muscles along with three leaflets: the septal, anterior, and posterior leaflets. The most common cause of tricuspid regurgitation (TR) is dilatation of the right ventricle, producing functional regurgitation with anatomically normal valve leaflets. This can be secondary to pulmonary hypertension from lesions of the mitral and aortic valves, or cor pulmonale. Other etiologies of TR are those that cause structural valve abnormalities. These include congenital malformations, rheumatic disease, degenerative disease, carcinoid disease, infective endocarditis, leaflet entrapment, leaflet scarring due to intracardiac pacemaker leads, or damage to the leaflets from lead extraction and chest radiation (Table 14.4).

TABLE 14.4

Causes of Tricuspid Valve Disease

Regurgitation Right ventricle dilatation (secondary tricuspid regurgitation) Infective endocarditis Rheumatic heart disease Congenital heart disease (Ebstein anomaly) Connective tissue disease Papillary dysfunction Ischemia/infarction

Radiation Pacemaker/extraction-related lead injuries Stenosis Rheumatic heart disease Carcinoid Congenital heart disease Infective endocarditis

The cause of tricuspid stenosis (TS) is most frequently rheumatic heart disease (>90%). Less common causes include carcinoid heart disease, infective endocarditis, and congenital heart disease (Table 14.4). B. Indications 1. Tricuspid regurgitation: As reflected in current guidelines (Table 14.5), interventions on the tricuspid valve are indicated when concomitant left-sided valve surgery is performed and severe TR or moderate functional TR exists. In the setting of long-standing significant pulmonary hypertension that has developed from mitral disease, it is important to consider that TR will likely not improve with left-sided intervention alone. Isolated TR can be well tolerated and medically managed, and as such intervention can often be avoided. Isolated tricuspid surgery may be considered for severe symptomatic TR that is refractory to medical therapy, or minimally symptomatic severe TR with progressive dilatation of the right ventricle (Table 14.5). 2. Tricuspid stenosis: Surgery is recommended for patients with severe TS undergoing surgery for left-sided lesions, or in patients with isolated TS that is severely symptomatic (Table 14.6). C. Contraindications. Patients who are too frail to tolerate an operation should not undergo surgical repair. This may be due to advanced age and comorbid conditions. STS risk score and EuroSCORE are assessment tools that can aid in identifying patients who are too high risk for surgery. The presence of cardiac cirrhosis should be carefully assessed, as this can be an important additional risk factor in these patients. TABLE 14.5

Summary of AHA/ACC Recommendations in Tricuspid Regurgitation

Level of Evidence Class I TV surgery is recommended for patients with severe TR undergoing leftsided valve surgery.

C

Class IIa TV repair can be beneficial for patients with mild, moderate, or greater functional TR at the time of left-sided valve surgery with tricuspid annular dilatation OR prior evidence of right-sided heart failure.

B

TV surgery can be beneficial for patients with symptoms due to severe primary TR refractory to medical therapy.

C

Class IIb TV repair may be considered for patients with moderate functional TR and pulmonary artery hypertension at the time of left-sided valve surgery.

C

TV surgery may be considered for asymptomatic or minimally symptomatic patients with severe primary TR and progressive moderate or greater RV dilatation and/or systolic dysfunction.

C

Reoperation for isolated TV repair or replacement may be considered for persistent symptoms due to severe TR in patients who have undergone previous left-sided valve surgery and who do not have severe pulmonary hypertension or significant RV systolic dysfunction.

C

AHA/ACC, American Heart Association/American College of Cardiology; RV, right ventricular; TR, tricuspid regurgitation; TV, tricuspid valve.

TABLE 14.6

Summary of AHA/ACC Recommendations in Tricuspid Stenosis Level of Evidence

Class I TV surgery is recommended for patients with severe TS at the time of operation for left-sided valve disease.

C

TV surgery is recommended for patients with isolated, symptomatic severe TS.

C

Class IIb PBTC might be considered in patients with isolated, symptomatic severe TS without accompanying TR.

C

AHA/ACC, American Heart Association/American College of Cardiology; PBTC, percutaneous balloon tricuspid commissurotomy; TR, tricuspid regurgitation; TS, tricuspid stenosis; TV, tricuspid valve.

D. Evaluation. A detailed history and physical examination should first

be obtained to identify symptoms and discern comorbidities and patient frailty. Transthoracic echocardiography is indicated to evaluate TR and TS. The valve anatomy, lesion severity, and associated defects can be identified. In the event of discordant or insufficient data, invasive hemodynamic measurements by right heart catheterization should be considered. For patients with severe TR and inadequate transthoracic echocardiograms, cardiac MRI can be an important tool for the assessment of right ventricular characteristics. E. Preoperative management. Maintaining sinus rhythm that preserves atrial contractions can help to improve cardiac output. Patients with regurgitation may benefit from a faster heart rate, and those with stenosis benefit from a slower rate. Diuresis can help to improve symptoms of right heart failure; however, elevated central venous pressures are necessary to drive forward flow through the right heart. F. Surgical intervention. Open surgical intervention (generally via full or partial sternotomy) on the tricuspid valve is achieved through a right atrial incision. 1. Repair of the tricuspid valve: The primary strategy for surgical repair of TR (which is predominantly functional) is ring annuloplasty. With dilatation of the right ventricle, the annulus is primarily distorted in the anterior–posterior axis because the septal wall and leaflet are more fixed. Annuloplasty rings are sutured in place to restore a normal size and shape and to promote leaflet coaptation. The rings may be complete or incomplete (open). Rings are designed to avoid placing stitches near the atrioventricular node and spare damage to the conduction system. Alternative strategies to repair the tricuspid valve include bicuspidization and annulus suture plication (DeVega technique) of the valve. 2. Replacement of the tricuspid valve: If the valve is not amenable to repair, it can be replaced with a prosthesis. Severe TS requires balloon valvuloplasty or replacement. Choices for prosthesis include mechanical, bioprosthetic (intra-annular or supraannular), or more rarely homograft (mitral valve tissue) versions. Mechanical valves do require lifelong anticoagulation, which must be considered. When implanting the valve, care is taken to avoid injuring the atrioventricular node. The leaflets and chordae of the valvular apparatus should be preserved.

G. Complications. Because of the proximity of the atrioventricular node and conduction system to the tricuspid annulus, there is risk for complete heart block postoperatively. In patients with both mitral and tricuspid prosthetic valves, late occurrence of complete heart block is approximately 25% at 10 years. If abnormalities in the conduction system are present preoperatively, an epicardial pacemaker lead can be placed at the time of surgery to avoid later transvenous lead placement through a repaired/replaced tricuspid valve. There is no difference in overall survival between patients with bioprosthetic and mechanical prosthetic tricuspid valves. However, mechanical valves carry a risk of thrombosis of approximately 1% per year. This complication is generally managed with thrombolysis. H. Outcomes. Tricuspid repair with annuloplasty rings yields up to 85% freedom from moderate-to-severe recurrent TR at 6 years. Rigid ring annuloplasty has greater freedom from recurrent regurgitation than suture plication or bicuspidization of the valve. TR most frequently occurs secondary to left-sided valve lesions, and it will often persist even after correction of the left-sided pathologic lesion. Although practice patterns are shifting toward concomitant TV annuloplasty at time of mitral repair, it is uncertain if long-term rates of right heart failure and mortality will decrease. Patients requiring simultaneous mitral and tricuspid valve replacement have operative mortality rates of 5% to 10%, and 55% at 10 years. Reoperations for tricuspid valve repair are associated with both high short- and long-term mortality rates.

KEY PEARLS • Isolated symptomatic severe MS and TS are treated first with balloon commissurotomy if valve anatomy is favorable. • Mitral valve posterior leaflet prolapse should be repaired with leaflet resection and annulus support with an annuloplasty ring. • Outcomes of mitral valve repair are dependent on etiology of the regurgitation. • TR is most commonly functional owing to right ventricular dilatation. • Repair of the mitral valve may not improve TR if long-standing pulmonary hypertension has been present. • During replacement of the mitral and tricuspid valves, care should be taken to maintain papillary or chordal attachments to the annulus.

SUGGESTED READINGS Cao C, Wolfenden H, Liou K, et al. A meta-analysis of robotic vs. conventional mitral valve surgery. Ann Cardiothorac Surg. 2015;4:305–314. Cohn LH, ed. Cardiac Surgery in the Adult. 4th ed. China: McGraw-Hill; 2012. Cohn LH, Tchantchaleishvili V, Rajab TK. Evolution of the concept and practice of mitral valve repair. Ann Cardiothorac Surg. 2015;4:315–321. Filsoufi F, Anyanwu AC, Salzberg SP, et al. Long-term outcomes of tricuspid valve replacement in the current era. Ann Thorac Surg. 2005;80:845–850. Griffin BP, Callahan TD, Menon V, eds. Manual of Cardiovascular Medicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013. Johnston DR, Gillinov AM, Blackstone EH, et al. Surgical repair of posterior mitral valve prolapse: implications for guidelines and percutaneous repair. Ann Thorac Surg. 2010;89:1385–1394. Kilic A, Shah AS, Conte JV, et al. Operative outcomes in mitral valve surgery: combined effect of surgeon and hospital volume in a population-based analysis. J Thorac Cardiovasc Surg. 2013;146:638–646. Mick SL, Keshavamurthy S, Gillinov AM. Mitral valve repair versus replacement. Ann Cardiothorac Surg. 2015;4:230–237. Mihaljevic T, Jarrett CM, Gillinov AM, et al. Robotic repair of posterior mitral valve prolapse versus conventional approaches: potential realized. J Thorac Cardiovasc Surg. 2011;141:72–80. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg. 2014;148:e1–e132. Rogers JH, Bolling SF. The tricuspid valve: current perspective and evolving management of tricuspid regurgitation. Circulation. 2009;119:2718–2725. Stout KK, Verrier ED. Acute valvular regurgitation. Circulation. 2009;119:3232–3241. Tang GHL, David TE, Singh SK, et al. Tricuspid valve repair with an annuloplasty ring results in improved long-term outcomes. Circulation. 2006;114:I-577–I-581. Vassileva CM, Mishkel G, McNeely C et al. Long-term survival of patients undergoing mitral valve repair and replacement: a longitudinal analysis of Medicare fee-for-service beneficiaries. Circulation. 2013;127:1870–1876.

I.

INTRODUCTION The aortic and pulmonic valves share similar structure and functional anatomy. Both prevent regurgitation of blood into the ventricle during diastole, and in normal function provide an unimpeded flow of blood from the ventricular outflow tract to the aorta or pulmonary artery (PA). Both are trileaflet in normal configuration, and rely on adequate coaptation of three similarly sized semilunar valve cusps for valve competence. Normal valve function depends on the shape and flexibility of the leaflets, size and orientation of the annulus and sinuses, and the orientation of the commissures between leaflets. Surgical therapy for the aortic and pulmonic valves may be appropriately categorized based on the indication —stenosis versus regurgitation, whether repair or replacement is feasible, whether any adjunctive procedures are required, and the surgical approach. Although the valves share similar anatomy, the pulmonic valve does not share a fibrous skeleton with adjacent valves as does the aortic valve (Fig. 15.1). This has important considerations for evaluation of sizing and concomitant valve procedures.

FIGURE 15.1 Relations of the aortic and pulmonic valves. Note the aortic, mitral, and tricuspid valves share a fibrous skeleton, whereas the pulmonic valve annulus shares a muscular connection with the other three valves.

II.

AORTIC VALVE INDICATIONS A. Aortic stenosis The most common indication for operation on the aortic valve is aortic stenosis (AS), and the most common cause of AS is degenerative valve calcification. Although small amounts of collagen disruption and calcific deposits on aortic valves are common in people without clinically evident aortic valve disease, significant aortic valve calcification is rare before the age of 30 years in patients with tricuspid aortic valves. Accelerated calcification may occur in patients with bicuspid or unicuspid valves. The histopathology of calcific AS is similar to that of atherosclerotic coronary disease, and shares similar risk factors at least in patients with tricuspid valve anatomy. This has prompted research into the potential for lipid-lowering therapy to alter the progression of calcific AS. Rheumatic disease of the aortic valve is characterized by an early

inflammatory phase consisting of edema, lymphocyte infiltration, and neovascularization. This is followed by a proliferative phase in which leaflets become thickened and retracted, with rolled edges and commissural fusion. Valve leaflets may become severely calcified, although annular calcification is rare. Congenital alteration in the number and orientation of the aortic valve leaflets may result in bicuspid (Fig. 15.2), unicuspid, or quadricuspid morphology. Of these, bicuspid valves are most common, and are present in approximately 2% of the general population, with a male to female ratio of 2:1. They are more common in first-degree relatives with bicuspid valves. The calcification present in stenotic aortic valves may be limited to the leaflets, or may extend into the annulus, interventricular septum, or anterior leaflet of the mitral valve. Calcium may exist primarily as surface deposits or extend deep into the surrounding tissues. Even mature lamellar bone formation may occur in very calcified aortic valves. Removal of invasive calcium requires care to avoid injuring surrounding structures, and when injury occurs reconstruction of the annulus with autologous pericardium or other material may be necessary. The distribution of calcification has implications for surgical approach and choice of valve prosthesis. Figure 15.3 shows the computed tomographic (CT) appearance of a heavily calcified unicuspid valve, with calcium invading into the ventricular septum. B. Aortic insufficiency Derangement in the integrity or morphology of the annulus, leaflets, or sinotubular junction may result in aortic insufficiency (AI). Dilatation of the aortic root is the most common cause of AI in North America. Dilatation of the sinotubular junction, with relative sparing of the leaflets and annulus, is associated with atherosclerotic ascending aortic aneurysm and AI in older patients.

FIGURE 15.2 Bicuspid aortic valve morphology. A: The common finding of fusion of the left and right coronary cusps, separated by a raphe. B: The uncommon “true” bicuspid valve with equal length cusps and only two commissures.

FIGURE 15.3 Computed tomographyic appearance of severe aortic valve calcification, in this case associated with a unicuspid valve, invasive into the ventricular septum.

Patients with degenerative calcific aortic valve disease often have a mixture of AS and AI; as leaflets become stiffened, fixed, and retracted, coaptation is impaired. In a similar fashion, rheumatic heart disease leads to AI through fixation of the leaflets. Congenital bicuspid valve disease may produce insufficiency via fibrosis and calcification in a manner similar to a degenerated calcified tricuspid valve. In addition, distortion and stretching of the leaflets

may result in malcoaptation, in which one leaflet overrides another leading to an eccentrically directed regurgitant jet. Aortic dissection often produces severe regurgitation in an otherwise anatomically normal valve when the commissures and associated intima are detached from the aortic adventitia and prolapse inward. Bacterial endocarditis may account for 10% or more of AI. Healed endocarditis lesions may present as an isolated leaflet perforation in an otherwise normal-appearing valve. Less common etiologies of regurgitation include injury to the valve from blunt or penetrating chest trauma, iatrogenic injury to the leaflets during catheter procedures, and suture injuries during mitral valve surgery. C. Pulmonic stenosis Pulmonic stenosis in developed countries occurs most commonly as a result of congenital heart defects, prior surgical or endovascular intervention, or rarely rheumatic disease. D. Pulmonic insufficiency Pulmonary insufficiency occurs mostly as a result of annular enlargement, congenital malformations, prior intervention, or pulmonary hypertension. III.

EVALUATION A. Aortic stenosis Noninvasive measurement of aortic valve gradients extrapolated from aortic jet velocity on two-dimensional echocardiography has been shown to be the most reproducible and accurate method of grading AS, such that catheter measurement of aortic valve gradients is uncommon except in select cases (see low-gradient AS, later). Recent reports have suggested that gated cardiac CT may provide more precise measurements of aortic valve morphology and area than echocardiography. Evaluation of AS by gated CT may be of particular value in patients being considered for transcatheter aortic valve implantation, because it provides data on the anatomic relationship between leaflet calcification and the coronary ostia (Fig. 15.4). Cardiac CT, cardiac magnetic resonance imaging (MRI), and three-dimensional (3D) echocardiography all have the potential to provide direct (anatomic) measurement of aortic valve area (AVA). However, they may all underestimate the functional severity of AS, which depends on

the dynamic interaction between the ejecting ventricle, outflow tract, and aortic valve orifice. Thus, a decision on timing for surgery in AS must take into account the etiology, chronicity, the condition of the ventricle, degree of concomitant AI, and the presence of associated valve or coronary lesions.

FIGURE 15.4 Computed tomographic evaluation of aortic valve calcium location and extent in relation to coronary ostia.

1. AS grading table

Grade

AVA (cm2)

Mild

>1.5

Moderate

1–1.5

2. Natural history Much has been learned about the natural history of AS since the landmark study published by Ross and Braunwald in 1968. The classic symptom triad of angina, syncope, and dyspnea has since served as a hallmark for the evaluation of patients with AS. These investigators reported a survival of 3 years with angina and syncope, 2 years with dyspnea, and 1.5 years with heart failure. These dismal survival statistics in untreated symptomatic AS, corroborated by a number of subsequent studies, have since driven recommendations for aggressive operative therapy in patients with symptomatic severe AS. The appropriate treatment of asymptomatic patients is more controversial, however. Estimates of the rate of sudden death in asymptomatic AS are generally in the range of 1% per year. In addition, one-third of asymptomatic patients with severe AS will become symptomatic within 2 years. Two-thirds of patients will proceed to aortic valve replacement (AVR) or cardiac death within 5 years of diagnosis. A significant proportion of “asymptomatic” patients have markers of more advanced disease such as severe left ventricular hypertrophy (LVH) or decreased ejection fraction (EF), and many have a positive stress test. Exercise stress testing is likely underutilized in this population. Asymptomatic patients with a positive stress test have a prognosis similar to that of symptomatic patients and should be offered early surgery. 3. Medical treatment Given the pathologic link between AS and coronary disease, there has been enthusiasm for using lipid-lowering drugs to slow the progression of leaflet disease. Despite high expectations, results have been mixed. The SEAS study, a randomized controlled trial of 1,873 patients with mild–moderate asymptomatic AS receiving simvastatin and ezetimibe or placebo, failed to show any reduction in AS-related events in the lipid-lowering arm. Efforts to find a medical treatment that is effective in reducing severity or

progression of AS are ongoing. At present, medical treatment in AS is aimed at hemodynamic stabilization in asymptomatic patients and control of comorbid conditions. Hypertension control may help alleviate LVH; however, overmedication raises the risk of decompensation in patients who are dependent on already reduced diastolic pressure for coronary perfusion in a hypertensive ventricle. Angiotensin-converting enzyme inhibitors have been shown to provide short-term benefit in hypertensive patients with AS. Atrial fibrillation may have a significant adverse impact in patients with AS who are particularly dependent on atrial contraction for diastolic filling; therefore, cardioversion and rhythm control are important considerations both before and after AVR. Endocarditis prophylaxis is indicated in all patients with AS. 4. Timing of intervention for AS Published guidelines support AVR in symptomatic patients with severe AS. Patients without clear symptoms, or with symptoms but equivocal echo findings present a clinical challenge. In these patients, the surgeon must weigh the individual risks of AVR with watchful waiting, which may include a potential for sudden cardiac death, as well as ongoing LV remodeling. LVH as measured on routine electrocardiogram is an independent predictor of symptom development in severe AS, albeit with low sensitivity. Development of symptoms during exercise stress testing is a predictor of symptom development within 12 months. Onset of symptoms in a patient with severe AS who has been previously asymptomatic portends a poor prognosis; however, patients often subconsciously reduce their activity levels and may therefore fail to report “symptoms.” Exercise testing may be particularly valuable in these patients. Iung et al. estimate that at least one-third of patients with symptomatic, severe isolated AS do not undergo surgical repair. These data have been confirmed in multiple studies; however, the number of untreated patients may decrease with wider application of transcatheter aortic valve replacement (TAVR). The fact that even elderly patients benefit from AVR in almost all cases and a large number of “asymptomatic” patients have markers for worse surgical outcome argues for an aggressive approach to early surgery.

5. Low gradient–low flow AS In this subset of patients with anatomic AS who do not demonstrate increased gradients at rest (12 hr apart; or All of three or a majority of ≥4 separate cultures of blood (with first and last sample drawn at least 1 hr apart) • Single positive blood culture for Coxiella burnetii or antiphase I immunoglobulin antibody titer >1: 800 Evidence of endocardial involvement • Echocardiogram positive for IE (transesophageal echocardiography recommended in patients with prosthetic valves, rated at least “possible IE” by clinical criteria, or complicated IE [paravalvular abscess]; transthoracic echocardiography as first test in other patients), defined as follows: Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation; or Abscess; or New partial dehiscence of prosthetic valve New valvular regurgitation (worsening or changing of preexisting murmur not sufficient) Minor criteria • Predisposition: predisposing heart condition or injection drug use • Fever: temperature >38°C • Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions • Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor • Microbiologic evidence: positive blood culture but does not meet a major criterion as noted above or serologic evidence of active infection with organism consistent with IE Diagnosis of IE is definite in the presence of Two major criteria, or One major and three minor criteria, or Five minor criteria

Diagnosis of IE is possible in the presence of One major and one minor criteria, or Three minor criteria

Adapted from Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30:633–638, with permission of Oxford University Press; HACEK group (Haemophilus spp. Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella spp., and Kingella kingae).

FIGURE 16.1 Diagnosis and treatment of IE.* Early surgery defined as during initial hospitalization before completion of a full therapeutic course of antibiotics. HF, heart failure; ICD, implantable cardioverter-defibrillator; IE, infective endocarditis; NVE, native valve endocarditis; PVE, prosthetic valve endocarditis; Rx, therapy; S. aureus, Staphylococcus aureus; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography; VKA, vitamin K antagonist. (Reproduced with permission from Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:2440–2492.)

TABLE 16.2

Indications for Surgery for IE

Class I Indications

Level of Evidence

Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE who present with valve dysfunction resulting in symptoms of heart failure.

B

Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms.

B

Early surgery (during initial hospitalization before completion of a full

B

therapeutic course of antibiotics) is indicated in patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions. Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5–7 d after onset of appropriate antimicrobial therapy.

B

Surgery is recommended for patients with PVE and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection.

B

Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE with documented infection of the device or leads.

B

Class IIa Indications Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection.

B

Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE.

B

Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy.

B

Class IIB indications



Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with NVE who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon).

B

IE, infective endocarditis; NVE, native valve endocarditis; PVE, prosthetic valve endocarditis. Adapted from 2014 AHA/ACC guidelines for the management of patients with valvular heart disease.

VI.

PREOPERATIVE PATIENT MANAGEMENT AND PLANNING A. When adequate blood cultures have been secured, an antibiotic regimen covering all suspected organisms should be initiated. Once the sensitivity of the organism has been confirmed, there is no additional benefit to delaying surgery to allow a longer period of preoperative antibiotic treatment. Outcomes are not related to the duration of antibiotic therapy before surgery. If the organism, however, happens to be insensitive to the antibiotics being administered at the time of surgery, the risk of recurrent infection is increased. Our infectious

disease colleagues, however, have reassured us that the chance of that happening is very low provided that the diagnosis of IE was suspected preoperatively. B. IE patients with neurologic symptoms who are scheduled for surgery should have neurologic evaluation and brain imaging, by either CT or MRI, within days of the planned operation to visualize any strokes and to determine if an infarct is ischemic or hemorrhagic. Imaging should be repeated in case of new or worsening symptoms. Because embolic events and strokes are so common in patients with IE, routine preoperative screening of asymptomatic patients, particularly those with high-risk vegetations, may be justified. The standard recommendation is that surgery should be delayed for 1 to 2 weeks in patients with nonhemorrhagic strokes and for 3 to 4 weeks in patients with hemorrhagic strokes to reduce the risk of further intracranial bleeding during heart surgery. We do not operate on patients with serious neurologic damage, unconscious patients, or those unable to follow simple commands until neurologic improvement has been demonstrated. Hemorrhagic lesions are associated with a higher probability of mycotic aneurysms, which often require treatment before valve surgery. Patients with intracranial bleeding must undergo cerebral angiography to exclude a mycotic aneurysm, although the yield will be low even in those with bleeding. For those with nonhemorrhagic embolic strokes, the main concerns are worsening the neurologic damage and hemorrhagic conversion of the infarct during the operation. The risk of worsening neurologic symptoms as a consequence of operation is time related, decreasing with increasing interval from the initial neurologic event. The risk of worsening the stroke symptoms must be weighed against the indications for surgery and the risk of additional emboli during the waiting period. If the patient is stable and risk of additional embolism deemed low, we try to delay surgery for 1 week, after which time we repeat brain imaging before operating. Mycotic aneurysms in other places are uncommon but do occur, as do satellite infections (brain, spine, or splenic abscesses in left-sided IE, pulmonary abscesses in right-sided IE). Imaging with CT or MRI of the chest and abdomen may be justified in select cases, for example, in patients with Aspergillus IE. Preoperative work-up should include cardiac catheterization in patients aged 40 years or older to exclude coronary disease on the

basis of normal criteria for risk of coronary disease. Clinical judgment should be exercised in patients with large vegetations on the aortic valve where there is some concern about provoking embolic events and in patients with renal impairment when cardiac catheterization is not absolutely necessary for planning of the operation. Safe sternal reentry in case of reoperation requires knowledge about structures at risk of injury, and all these patients should undergo chest CT without contrast; MRI does not provide the same information. When arterial structures such as the ascending aorta, a pseudoaneurysm, or an important graft are in direct contact with the sternum, consideration should be given to peripheral cannulation (preferably via the axillary artery) and institution of cardiopulmonary bypass before sternotomy. VII.

THE SURGERY A. General principles 1. Objectives of surgery for IE are to prevent additional embolic events, to debride and remove all infected tissue and foreign material (disrupt the biofilm), and to restore functional valves and cardiac integrity. If infection is limited to valve cusps or leaflets (referred to as “simple” IE) of a native valve, replacement with either biologic or mechanical valve prosthesis according to the same principles as for noninfected valves is acceptable. There is no evidence that a bioprosthesis is better or worse than a mechanical valve with regard to risk of recurrent IE, but in patients with neurologic complications and for very sick patients, biologic valves may be preferable to avoid adding complexity to postoperative management by committing the patients to anticoagulation required for mechanical valves. 2. Patients with extravascular invasion beyond the cusps or leaflets require radical debridement and reconstruction, and this is easier to accomplish for the aortic valve and root than for the mitral valve. Aortic root infections are much simpler to expose and debride. The anatomy, access, and use of an allograft for reconstruction make both radical debridement and subsequent reconstruction easier with advanced aortic IE than with advanced mitral valve IE. Radical debridement with removal of all infected and necrotic tissue and foreign material is difficult to accomplish in mitral cases with AV groove invasion, necrosis, and abscess formation, and we do not

have a reconstruction valve for the mitral position that is comparable to an aortic allograft. 3. Intraoperative TEE is mandatory in all cases of IE. B. Aortic valve endocarditis 1. In every IE case, we look carefully for invasion because a small entry may hide an extensive extra-aortic spread of the infection (see Figure 16.2). Radical resection of all infected tissues and foreign material (prosthesis, pledgets, and sutures) is necessary, followed by reconstruction. If the patient has heart block of any degree, the infection is close to the AV node and bundle of His; a good understanding of the anatomy and mastery of different options for root reconstruction is required if these operations are to be safe and successful. 2. An aortic allograft is our preferred choice for reconstructing the aortic root, but use of an allograft is no substitute for radical removal of all infected tissues: Allografts are more resistant than prosthetic valves, but not immune to reinfection. We prefer untreated autologous pericardium when extra material is required. C. Mitral valve endocarditis 1. Radical resection of all necrotic tissue is performed with caution, although all grossly infected tissue must be removed. When the infection involves mitral annular calcification, all infected calcium has to be debrided. Unaffected leaflets, chordae, and papillary muscles are preserved to allow repair, or to at least offer some support for the posterior annulus. 2. For NVE, repair is preferred and can be performed safely as long as sufficient tissue remains to guide the reconstruction. Standard repair techniques are applied. Successful repair can be achieved by an experienced surgeon in up to 80% of patients. Although it is desirable to avoid extra foreign material during surgery for IE, use of a prosthetic annuloplasty ring in NVE may be necessary to provide a durable repair and has a low risk of infection. The benefits of a good and durable repair outweigh the very low added risk of recurrent infection. If repair is not technically feasible and the valve must be replaced, the choice of valve follows the normal principles of valve surgery. 3. Fortunately, only a third of mitral IE cases are invasive, and the invasion is often shallow, even for PVE, and generally does not require extensive debridement and reconstruction. Deep invasion

and destruction of the posterior annulus require removal of all necrotic and devitalized tissue as well as old suture material. When invasion is deep into the AV groove, debridement must be performed with utmost care, mindful of the complex anatomic relationship in the area and need for reconstruction. Annulus reconstruction is performed with untreated autologous pericardium. Patching the entry to the cavity means the cavity is not drained and therefore has to be sterilized. From an infection standpoint, drainage to the atrium or the pericardium is preferable when possible. In most invasive cases, valve replacement is required. Occasionally, the posterior leaflet contour and chordae are preserved to allow repair of the annulus and leaflet, even in cases with posterior invasion. VIII. DOUBLE-VALVE ENDOCARDITIS Most double-valve IE cases are primarily aortic valve IE with jet or kissing lesions in the anterior mitral valve leaflet. These are localized secondary lesions, which can be easily dealt with by excision and an autologous pericardial patch. Destruction of the intervalvular fibrosa (IVF) usually occurs in the setting of PVE affecting both the aortic and mitral valves, although it can also occur with native valve infections. Radical debridement of infected tissue and foreign material may have to include all or parts of the IVF and require its reconstruction with autologous (or bovine) pericardium as well as replacement of both the aortic and mitral valves. IX.

RIGHT-SIDED IE A. IE involving the right-sided valves, primarily the tricuspid valve and rarely the pulmonary valve, is an increasing problem that accounts for 5% to 10% of patients with IE. B. Intravenous drug use remains a leading cause of right-sided IE in the Western world, despite both patient profile and the spectrum of causative organisms changing as a result of an increasingly aging population with degenerative valve disease, patients with prosthetic valves, those exposed to nosocomial infections, increasing cardiac interventions like pacers/defibrillators, and increasing staphylococcal infections. Decisions regarding surgery are affected by concerns about continued intravenous drug use and recurrent IE. C. S. aureus is the dominant organism (60% to 90%); Pseudomonas

aeruginosa, other gram-negative organisms, fungi, enterococci, streptococci, and polymicrobial infections are responsible for the rest. Infections on the right side of the heart are never invasive beyond the valve, so isolated right-sided IE responds better to antibiotic treatment and has low in-hospital mortality (2 mm in diameter, indicating myxomatous, degenerative, or inflammatory disease. Mitral annular calcification can also be visualized with a precise determination of its extension into the valve leaflets. Rarely, cardiac CT is extremely helpful to differentiate tumors from “caseous” mitral annular calcification. B. Quantification of severity 1. Severity of MR is usually calculated indirectly by subtracting the aortic systolic flow from the LV stroke volume. In patients with MR, the total LV stroke volume is increased to compensate for the volume regurgitating into the left atrium; this volume can be calculated by acquiring serial SSFP cine images of short-axis stacks of the left ventricle from base to the apex followed by counting and measuring the LV volumes, as described earlier for LV volume assessment for AR. This provides the total LV volume, which comprises both stroke volume and mitral regurgitant volume. Calculating the stroke volume from the phase-contrast imaging of the aortic valve is done by placing the flow mapping slice at the level of the valve and acquiring both magnitude images and phase velocity maps as described earlier, in the aortic regurgitation section, to determine the stroke volume. Finally, subtracting the aortic forward flow (stroke volume) from the total LV volume equals the mitral regurgitant volume. Regurgitant fraction can be calculated by computing regurgitant volume/LV volume × 100%. This method of calculation relies on a combination of two different MRI techniques (phase contrast and counting LV volumes through cine images), so care is required to minimize the errors while acquiring the flow sequences and LV contours. Also, this method can only be used to determine whether the MR is a single-valve lesion. 2. The quantification of MR correlates well with echocardiography and catheter-based assessment with good reproducibility. In addition, cardiac MRI quantification of MR provides a threshold

for predicting the patients suitable for early mitral valve replacement or repair when the regurgitant fraction is 40% or greater. Large-scale clinical trials are required to validate and identify these patient populations. 3. Patients with acute myocardial infarction and associated MR as well as patients with chronic MR secondary to potential hibernating myocardium can be identified by cardiac MRI with the help of delayed enhancement imaging. This helps with decisions regarding the benefit and role of revascularization of the involved arterial territory and also whether valve repair or replacement versus revascularization alone will be required. Delayed enhancement imaging represents a noninvasive method to assess myocardial fibrosis. It has been shown that the presence of delayed enhancement on CMR is associated with less favorable outcomes in multiple cardiovascular diseases. Recent findings have suggested that lateral wall and papillary muscle infarct leads to a higher incidence of associated MR in patients with acute myocardial infarction. The lack of viability in the lateral wall of the left ventricle evaluated by delayed enhancement may suggest poor outcome with revascularization alone compared with accompanying mitral valve repair or replacement. Delayed enhancement imaging was also shown in patients with primary MR to be a marker of LV remodeling. 4. There are newer methods under clinical investigation to further strengthen cardiac MRI quantification of MR. One of these is 4D flow cardiac MRI for quantification of MR, which is independent of hemodynamic and geometric assumptions. It has the capability to retrospectively position the image plane in the direction of regurgitation and analyze multiple jets with separate image planes. However, no gold standard is currently available to validate 4D flow cardiac MRI. Clinicians are waiting for long-term clinical trials before including 4D flow quantification into everyday clinical cardiac MRI protocols. C. Procedural assessment 1. Minimally invasive mitral valve repair (i.e., right thoracotomy and robotic approaches) has been proposed as an alternative technique for invasive open-heart surgery. However, because of the requirement for peripheral cardiopulmonary bypass, cardiac CT is utilized for preoperative assessment of systemic arterial and

vascular anatomy to determine the risk of embolic complications and to assess coronary arteries. In patients anticipating minimally invasive surgeries, the presence of significant aortoiliac atherosclerosis may dictate a change to a more standard surgical approach with central cannulation. 2. Cardiac CT also provides an opportunity for precise measurement of the mitral valve orifice size used for upcoming transcatheter mitral valve implantation. Furthermore, cardiac CT can precisely assess mitral valve calcification before mitral valve balloon valvuloplasty for rheumatic mitral valve stenosis. VI.

PULMONARY STENOSIS The pulmonary valve is a delicate semilunar valve with three cusps (anterior, right, and left) and lacks coronary ostia. Pulmonary stenosis is a congenital disorder in almost 95% of cases. Acquired pulmonary stenosis is extremely rare, with few cases noted secondary to rheumatic fever or carcinoid heart disease. Pulmonary stenosis may affect RV function by elevating RV pressure, resulting in RV hypertrophy, dilatation, and dysfunction. The pulmonary valve can be difficult to assess by echocardiography because of its location behind the sternum. RV function is also difficult to assess, particularly by volumetric analysis, secondary to its complex shape. Cardiac CT is useful in detecting the poststenotic dilatation of the main and left pulmonary artery. Usually, the right pulmonary artery is normal in size, as the turbulent flow from pulmonary stenosis is directed posteriorly toward the left pulmonary artery. The 4D cine images may show restricted and thickened pulmonary valves. Similar to aortic valve area, pulmonary valve area measurement by planimetry is also feasible and should be performed during midsystolic frames to infer stenosis severity. RV function can also be analyzed using 4D cine retrospective imaging as described earlier, to precisely calculate RV volume and function. Cardiac CT can help in assessing the pulmonary valve and RV function. Its use for serial assessment is less valuable given concerns about radiation exposure. Cardiac MRI is the gold standard for assessment of the pulmonary valve and RV outflow tract (RVOT). It facilitates easy identification of location (valvular, supravalvular, or subvalvular) and severity of pulmonary stenosis. Acquiring a precise cine RVOT image can help to qualitatively assess the severity of pulmonary stenosis by visualizing the stenotic jet and valve motion. Quantitative assessment and direct

planimetry can be performed similar to AS. Peak velocities can also be obtained similar to AS through in-plane velocity mapping. RV function can be precisely measured by volumetric analysis as described earlier, for optimal surgical planning. VII.

PULMONARY REGURGITATION Significant pulmonary regurgitation is most common in patients with congenital heart disease, largely in patients with surgically repaired tetralogy of Fallot. Trace to mild pulmonary regurgitation is a common finding in normal individuals. Cardiac MRI has transformed the accuracy of quantitative assessment of severity of pulmonary regurgitation and determination of RV volume and function. RVOT cine imaging can qualitatively predict the severity of regurgitation, though through-plane phase-contrast velocity mapping with the image slice just above the pulmonary valve, without any aliasing, can accurately quantify pulmonary regurgitation. A regurgitant fraction >40% is considered severe pulmonary regurgitation (Fig. 17.5). Accurate measurement of RV volumes and function is important for timing of surgery. Abnormal septal motion gives an indirect measure of RV pressure and volume overload, particularly in short-axis cine images. Severe pulmonary regurgitation with an RV end-diastolic volume index 90%) and has demonstrated that the posterior or septal leaflets are usually involved (Fig. 19.6). D. Pulmonic valve. 2D echocardiographic assessment of the pulmonic valve is particularly challenging in most subjects due to the valve being positioned the furthest from the transducer on both TTE and TEE imaging. In addition, only two-valve leaflets can be demonstrated at any one time on standard 2D imaging planes. 3D echocardiography, therefore, provides a significant advantage by enabling the valve to be visualized en face, with all three valve leaflets displayed simultaneously. However, 3D assessment of the pulmonic valve still remains less successful than the other valves, as a result of the same echo-penetration issues plaguing 2D imaging, which result in suboptimal image quality from echo dropout. Overall, the pulmonic valve can be accurately demonstrated in three dimensions in approximately 60% of all echocardiograms.

FIGURE 19.6 Three-dimensional full-volume reconstruction of the right heart, cropped to demonstrate the pacing lead (white arrow) traversing the tricuspid valve in a long-axis right ventricular optimized view (A) and a short-axis en face view (B) of the tricuspid valve from the right ventricular aspect. Tricuspid valve leaflets are labeled anterior (Ant), septal (Sept), and posterior (Post).

1. Pulmonary stenosis. Congenital heart disease is the most common cause of pulmonary stenosis, although carcinoid disease can also result in significant restriction of leaflet opening and hemodynamically significant stenosis. Congenital stenosis can also involve supravalvular, subvalvular, or infundibular stenosis, such as that seen with a double-outlet right ventricle. Although adequate imaging of the right ventricular outflow tract and pulmonic valve is not possible in all subjects, when image quality is preserved, 3D images are accurate and provide useful information for diagnosis, functional assessment, and further interventional planning. 2. Pulmonary regurgitation. The etiology of clinically significant pulmonic regurgitation is also typically congenital heart disease or carcinoid valve disease. En face 3D imaging of all valve leaflets is relevant in both these situations to determine morphology and function. 3D echocardiography enables recognition of the thickened, restricted, and retracted leaflets typical for carcinoid valvulopathy. Valve mobility can be assessed, in addition to 3D color Doppler interrogation for determination of regurgitation

severity. Like the other valves, regurgitation severity can be calculated using MPR techniques to accurately planimeter the vena contracta area. An additional advantage of 3D over 2D echocardiography is that the right ventricular outflow tract area can be accurately measured in any orientation, using 3D MPR techniques. This removes the assumption that the outflow tract is circular and allows the true area to be substituted into the continuity equation for more accurate calculation of the regurgitant volumes and fractions. E. Prosthetic valves 1. 3D echocardiography and 3D TEE in particular have revolutionized the assessment of prosthetic valve function, along with diagnosis and assessment of associated complications. En face imaging provides detailed information about the entire valve structure simultaneously. This includes normal structures such as leaflets, annular rings, and stent struts, as well as abnormal pathology such as vegetations, thrombi, or abnormal sutures. The addition of 3D color Doppler can also localize paravalvular leaks, valve dehiscence, and valvular regurgitation. 2. Prostheses in the mitral position are most reliably demonstrated by 3D TEE. Although conventional views may be hampered by valve shadowing, the ability of 3D cropping and acquisition in nonconventional imaging planes means that in most situations the mitral valve including all leaflets can be visualized regardless of original position or orientation. Aortic and tricuspid prosthetic rings are reliably demonstrated in three dimensions; however, the leaflets may be less well visualized. This may relate to the increased depth of the leaflets relative to the transducer or to technical factors associated with the angle of the ultrasound beam. Reliable 3D imaging of pulmonic valve prostheses is also currently limited. Ongoing optimization of 3D techniques and technology, with smaller transducers and higher frame rates, is required before all prosthetic valves can be adequately and reliably imaged at an adequate standard for diagnostic purposes. F. Endocarditis. 3D TEE is a useful and complementary technique to 2D TEE for assessment of native and prosthetic valve endocarditis. However, the lower frame rates and reduced spatial resolution of 3D TEE relative to 2D TEE make it less sensitive for identification of smaller, highly mobile lesions. An advantage of 3D TEE is its ability

to visualize the entire valve and therefore precisely identify the location of vegetation adherence and any associated leaflet, annular, or prosthetic complications. Off-axis imaging in any orientation using narrow-angle zoom images or cropping of 3D data sets also enables manipulation of image angles to best demonstrate the exact relationship of vegetations to valvular and nonvalvular structures. In some cases, this allows visualization of lesions not appreciable with 2D echocardiography. This may result in better mass characterization and differentiation of vegetations from other structures such as thrombi, prosthesis pannus, small tumors, or mobile suture material. 3D imaging is particularly useful and important for prosthetic valve dehiscence or paravalvular leaks, where images may require extensive rotation or manipulation to locate the precise defect and to plan and potentially guide percutaneous interventions. 3D color Doppler is also useful in this setting for quantification of regurgitant jets and identification of jet origins to localize valve pathology including perforations and prosthesis dehiscence. G. Congenital heart disease 1. A further important clinical application of 3D echocardiography is congenital heart disease. The improved spatial orientation provided by 3D imaging not only identifies discrete structural abnormalities but also enables better conceptualization of these defects relative to the entire heart, while providing simultaneous functional information. In congenital valvular disease, this greater flexibility in off-axis imaging enables a better understanding of complex lesions and previous repairs. In some cases, this may negate the requirement for additional invasive catheterization or tomographic cardiac CT or MRI. 2. 3D echocardiography can be particularly helpful for direct visualization of structural abnormalities in conditions such as endocardial cushion defects with a cleft mitral valve, sub- and supravalvular stenosis, pulmonary valve pathology, and Ebstein anomaly. Preoperative assessment of these structures from nontraditional en face views may allow better determination of defect repairability and consideration of alternative operative strategies preoperatively. IX.

3D ECHOCARDIOGRAPHY FOR PROCEDURAL PLANNING, GUIDANCE, AND OUTCOMES

A. Transcatheter aortic valve replacement. The utility of 3D echocardiography is perhaps best demonstrated in its central role for percutaneous aortic valve replacement. Arguably, this percutaneous technique would have been less available and less successful without the preoperative assessment and intraprocedural guidance provided by 3D TEE. The aortic valve lies in close proximity to several important structures and, hence, accuracy of distance and area measurements for any intervention in the region is crucial. Typically, this is best achieved using MPR techniques, whereby the smallest valve area, largest annular and root dimensions, and distance to the coronary ostia can all be accurately defined. 1. Preprocedural assessment for TAVR a. Preprocedural assessment involves complete qualitative assessment of aortic valve morphology and function by 2D and 3D TEE. MPR processing is then typically employed on-cart or offline to determine specific measurements, crucial to determine suitability for TAVR and for prosthesis sizing. The accuracy of these measurements is made feasible by the ability of 3D MPR to obtain perfect orthogonal alignment of the LVOT and the aortic annulus. Measurements include aortic annular dimensions (including distance, area, and circumference), distance from the aortic annulus to the coronary artery ostia, and smallest cross-sectional aortic valve area to confirm stenosis severity (Fig. 19.7). If the annulus is too small, too ovoid, or too large, significant procedural issues can result including annular rupture, paravalvular leak, or valve embolization. Oversized valves also potentially increase the risk of damage to the conduction system, which runs in close proximity to the aortic annulus. The currently available, purpose-designed, low-profile, percutaneous aortic valves typically range from 23 to 29 or 31 mm in size, depending on vendor. Suitable annular measurements for each sized valve vary slightly between manufacturers. However, for example, the Edwards SAPIEN three valves are suitable for a range of annular diameters between 18 and 27 mm and areas of 338 to 680 mm2. Although the low-profile nature of the percutaneous valves means that they are relatively unlikely to obstruct coronary ostia, the annulus to coronary distance should be confirmed for suitability during the initial preprocedural

assessment. Assessment of the length of the native valve leaflets is also important, relative to the annulus to coronary distance, as longer leaflets have potential for coronary ostia obstruction after TAVR deployment. b. The preprocedural MPR measurements performed for TAVR have been shown to be highly reproducible and correlate better with dimensions achieved via tomographic imaging with CT and MRI than 2D TEE measurements. Although 3D TEE annular measurements are consistently larger than by 2D echocardiography, they tend to run smaller than those achieved with CT and MRI. This needs to be remembered during selection of valve size. Most TAVR centers continue to perform preprocedural planning assessment with both 3D TEE and gated cardiac CT or noncontrast cardiac MRI (in the setting of renal dysfunction). Combining techniques provides confirmation of these important measurements and maintains the invaluable functional data provided by 3D TEE. 2. Procedural TEE for TAVR. Echocardiography remains integral for procedural guidance during TAVR. Typically, this involves TEE, but particularly in Europe, some centers are performing awake procedures with TTE assistance. Although valve positioning is predominantly determined by fluoroscopy, TEE remains useful for catheter guidance and confirming that the valve is appropriately sited and deployed. If a valve is deployed too far into the aortic root, the coronary ostia can become obstructed. Conversely, if the valve is positioned low in the LVOT, disruption to the geometry of the aortomitral curtain or impingement of the anterior mitral valve leaflet can result in mitral valve dysfunction and mitral regurgitation. 3. Postprocedural TAVR. The role of postprocedural echocardiography in TAVR is to monitor for specific complications including valvular or paravalvular aortic regurgitation, new wall motion abnormalities, and more serious sequelae such as annular rupture and pericardial effusion. Determination between valvular and paravalvular aortic regurgitant jets is not always clear on standard 2D color Doppler imaging, which may require multiple imaging planes. 3D TEE is ideally suited for this purpose, as the valve can be orientated en face and the jet origins can be identified with the addition of 3D color Doppler. Confidently demonstrating

these jets and being able to demonstrate them online in real time during the procedure means that these results can be visually communicated to the interventionalist or surgeon in a clear and logical manner. In cases of significant aortic regurgitation or valve malposition, these results may then guide the operator with further intervention including valve-in-valve deployment or paravalvular closure devices. In the rare event of catastrophic complications such as annular rupture, prompt and accurate diagnosis by 3D echocardiography can save precious minutes and facilitate rapid resuscitation and surgical intervention.

FIGURE 19.7 Three-dimensional transesophageal echocardiography multiplanar reconstruction techniques can be used to determine the annular dimensions and area for transcatheter aortic valve replacement sizing. This involves determining the cross-sectional area of the annulus in three axes (x, y, and z) with two-dimensional image planes and then creating a three-dimensional reconstruction from which accurate measurements can be directly performed on-cart or offline.

B. Paravalvular closure devices 1. In this era of increasing percutaneous intervention, a multitude of percutaneous closure devices are now available. Increasingly, these devices are being successfully used for closure of paravalvular leaks. 3D echocardiography and 3D TEE in particular are crucial for these interventions. Preprocedure, 3D imaging enables accurate localization and sizing of single or multiple defects. 3D evaluation

is particularly important for determining the defect shape as some large, elliptical, or asymmetrical defects are not suitable for device closure and need to be preemptively excluded from consideration and managed surgically. Imaging in two dimensions may infer a false degree of defect in geometrical symmetry and hence result in patients being inappropriately referred for device closure. The defect can be initially visualized in its entirety with 3D zoom or full-volume cropping techniques. MPR can then be used to make accurate defect measurements, and finally 3D color Doppler can quantify the leak size and confirm the leak position and direction. These accurate defect dimensions also assist with selection of device type and size. 2. Paravalvular leak closures for aortic and mitral valve prostheses are most common, related to the higher prevalence of left-sided valve replacements. Intraprocedure, like other percutaneous techniques, 3D TEE can be used for catheter guidance and device placement. Universally, in paravalvular leak closure the defect must be crossed by a guide wire to allow subsequent passage and deployment of the closure device in the appropriate position. The wire may be placed via an antegrade or retrograde approach, depending on the access site, defect location, and technical factors. Positioning of the guide wire using 2D techniques such as fluoroscopy or 2D TEE can at times be challenging, especially if the defect is small, has a large regurgitant jet, or is oblique in direction. Switching between different off-axis 2D imaging views can be cumbersome and add unnecessary complexity to these procedures, which could otherwise be guided by single en face 3D views. 3D imaging assists in these situations by demonstrating the defect and its surrounding structures, catheters, balloons, and devices in a simultaneous and more anatomically realistic fashion, thereby providing better geometrical orientation and guidance to the interventionalist. C. Balloon valvuloplasty 1. Typically, balloon valvuloplasty is most commonly performed for rheumatic mitral stenosis, although in some situations aortic valve balloon valvuloplasty may be performed in a high-risk or unstable individual as a bridge to percutaneous or surgical aortic valve replacement. Fluoroscopic guidance has been traditionally employed for this technique; however, the increasing availability

of intraprocedural 3D TEE has been a valuable addition. 3D imaging assists with guiding balloon placement and also for assessment of postprocedural results and complications. These include the degree of commissural splitting, presence of leaflet tears, and degree of postprocedural regurgitation using 3D color Doppler. 3D MPR imaging can also be employed to accurately determine the change between pre- and postprocedural valvular stenosis via planimetry. This method can be a useful alternative to 2D estimates of MVA immediately postvalvuloplasty, which tend to be less reliable and discrepant when compared with valve areas calculated using the Gorlin formula.

FIGURE 19.8 Three-dimensional transesophageal echocardiography zoom imaging demonstrates a bileaflet, mechanical mitral valve replacement with a vascular plug (Amplatzer Vascular Plug II device) deployed inferoposteriorly for percutaneous device closure of a paravalvular leak (arrow). The patient had presented with a mild to moderate paravalvular leak, adjacent to the inferoposterior aspect of the mitral valve sewing ring, and associated hemolysis.

2. Appropriate patient selection and suitability for balloon valvuloplasty is paramount. Traditionally, this has been guided by the Wilkins score, which grades suitability for valvuloplasty on the basis of the amount of leaflet mobility and thickness, valvular calcification, and subvalvular thickening. Perceived weakness in the Wilkins score has resulted in the recent development of a 3D echocardiography-based score. This technique involves a more regional assessment of valvular abnormalities, by evaluating each leaflet segment and subvalvular apparatus individually. This includes separate assessment of the commissures, which are typically the most crucial determinants of procedural success. Each regional score is finally weighted according to its predetermined importance for procedural success, before the individual scores are summed to give a total score graded from 0 to 31. Mild mitral valve involvement was defined as a total score of RVEDP. Unlike the RA, there is not usually an a-wave seen on the RV tracing. If there is an a-wave, it will be seen just before RVEDP and is only seen in states of decreased RV compliance, such as volume overload, RV hypertrophy, or pulmonary hypertension. 3. Pulmonary artery pressure a. Under normal circumstances, PA pressure is 20 to 30 systolic/4 to 14 diastolic mm Hg. Similar to other arterial waveforms, the PA tracing has a rapid rise, well-defined peak, a dicrotic notch (from pulmonic valve [PV] closure), and a well-defined nadir in diastole (Fig. 20.1). PA systolic pressure (PASP) should approximate RV systolic pressure (RVSP), unless there is pulmonic stenosis (PS), in which case RVSP > PASP. Furthermore, while PASP and RVSP are usually similar in magnitude, there is individual variability and these values may differ under normal conditions in certain patients. b. Comparing the RV and PA tracings, important identifying features are the approximately 5 mm Hg increase in diastolic pressure from the RV to the PA, and the appearance of the dicrotic notch in the PA. Also, the events of the PA waveform are slightly delayed with regard to the ECG, with the PASP peaking within the T-wave on ECG. 4. Pulmonary capillary wedge pressure a. The PCWP has a normal range of 4 to 14 mm Hg, and a-, c-, and v-waves similar to an atrial waveform (as it approximates LA hemodynamics) (Fig. 20.1). Unlike an atrial waveform, there is a delay in the pressure transmission from the LA across the pulmonary veins and pulmonary capillary bed. This delay usually places the a-wave after the QRS and v-wave after the T-wave on ECG. Additionally, unlike the RA tracing, the cwave is not visible on the PCW tracing due to pressure dampening, and the v-wave typically exceeds the a-wave in amplitude.

b. The PCWP is typically reported as a mean with a normal value approximately 0 to 5 mm Hg lower than PA diastolic pressure, unless there is elevated pulmonary vascular resistance. Changes in thoracic pressure during the respiratory cycle alter the PCWP tracing baseline, and mean PCWP is typically measured at end expiration (corresponding to the “peaks” in normal patients, and “valleys” in patients intubated undergoing mechanical ventilation). It may be helpful in awake patients with substantial respiratory variation in pressure to simply hold their breath, but they should be advised not to take a deep breath (or exhale) before this hold. c. While under ideal circumstances, PCWP approximates LA pressure (which approximates LVEDP), this rests on several assumptions, including no impedance of flow distally. PCWP will not correlate with LA pressure in the presence of pulmonary vein stenosis, and LA pressure will be a poor surrogate for LVEDP in patients with MS, severe mitral regurgitation (MR), severe AI, or poor LV compliance. Additionally, the presence of positive end-expiratory ventilation and improper RHC placement will decrease the reliability of the PCW tracing. 5. Left ventricular pressure. Normal LV pressure is 90 to 140 systolic/10 to 16 diastolic mm Hg, and similar to the RV waveform is characterized by a rapid upstroke and rapid decline. Diastolic pressure slowly rises during diastole to LVEDP, which is measured at end expiration just before the rapid upstroke during systole. Similar to the RV tracing, an a-wave is not usually seen except under circumstances of LV noncompliance. Simultaneous LV, arterial pressure, and PCWP are shown in Figure 20.2.

FIGURE 20.2 Simultaneous radial artery, left ventricular, and pulmonary capillary wedge pressure tracings.

6. Aortic pressure a. Central aortic pressure is typically measured in the aortic root or ascending aorta, and normally measures 90 to 140 systolic/60 to 90 diastolic mm Hg. Similar to other arterial tracings, there is a rapid upstroke to a well-defined peak and gradual decline that is interrupted by a dicrotic notch, which is caused by closure of the aortic valve (AV). b. Aortic systolic pressure should equal LV systolic pressure in

the absence of obstruction within the LV, at the level of the AV (i.e., aortic stenosis [AS]), or proximal aorta (i.e., supra-aortic membrane). While not normally seen, an “anacrotic” notch may be present during systolic pressure rise in patients with turbulent flow during ejection (i.e., severe AS). c. Simultaneous LV and aortic pressures are often measured when assessing for AS to determine transvalvular gradient (further discussed later). While femoral (or radial) arterial sheath pressures are sometimes substituted for central aortic pressures, differences between peripheral arterial sheath pressures and central aortic pressures are common. For instance, central aortic pressure may be higher than femoral (or radial) arterial sheath pressure in patients with peripheral arterial disease, sheath kinking, arterial tortuosity, or sheath thrombosis. Conversely, peripheral amplification of reflected arterial pressure waves may cause the peripheral arterial sheath pressure to be greater than central aortic pressure in certain individuals. B. Measurement of cardiac output. Invasive assessment is the gold standard for determining CO. Normal CO increases in accordance to meet systemic oxygen demand. Thus, any factor that influences systemic oxygen demand influences CO. In the simplest terms, CO is the product of heart rate (HR) and stroke volume (SV): CO = HR × SV As CO is greater with body size, CO is typically normalized to body surface area (BSA), resulting in the cardiac index (CI): BSA (m2) = √((Ht [cm] × Wt [kg])/3,600) CI = CO/BSA Normal values for CO range between 5 and 6 L/min, whereas normal values for CI range between 2.6 and 4.2 L/min/m2. The two major methods for determination of CO in the catheterization laboratory are the Fick technique and thermodilution technique. 1. The Fick technique a. The Fick equation is the most commonly used method for calculation of CO. The Fick equation is based on the principle that the total uptake (or release) of a substance by a tissue (i.e.,

lungs) is proportional to the blood flow to the tissue multiplied by arteriovenous (A-V) concentration difference of the substance. Assuming there is no intracardiac shunt, blood flow into the pulmonary circuit should equal blood flow into the LV and systemic circuit, thus:

b. O2 consumption can be measured by subtracting the O2 uptake from room air using a Douglas bag, metabolic hood, or a cardiopulmonary exercise testing machine. Given the limited availability, cost, and time involved in utilizing these methods, most laboratories use an assumed oxygen consumption of 125 mL/min/m2, or 3 mL/min/kg. c. The A-V O2 saturation difference across the lungs is then obtained by taking the difference between pulmonary venous blood O2 saturation (or systemic arterial O2 saturation, Sao2) and the PA O2 saturation (or “mixed venous” O2 saturation, Svo2). This difference is then multiplied by the O2-carrying capacity of hemoglobin (Hb) to obtain the A-V O2 content difference: (A-V) O2 content difference = (Sao2 – Svo2) × 1.36 mL/O2/g Hb × g Hb/dL blood × 10 The final formula for calculation then becomes:

d. Use of systemic arterial blood to estimate pulmonary venous blood O2 content is typically acceptable in the absence of a shunt, as only a small amount of venous blood enters the arterial circuit within the heart via the thebesian veins. Use of central venous blood (Scvo2 from the venae cavae [i.e., from a central line]) is less accurate. At rest, Scvo2 is lower than Svo2, as Scvo2 contains only superior vena cava (SVC) blood (which

has higher oxygen extraction from the brain), and Svo2 contains both SVC and inferior vena cava blood. 2. The thermodilution technique. Alternatively, CO may be estimated via an indicator dilution method, most commonly via the thermodilution technique. During thermodilution, a bolus of roomtemperature saline is injected into the RA. The temperature of the blood in the PA is continuously measured by a thermistor on the end of the PA catheter (6 to 10 cm away) and graphed as a function of time. The resulting curve is analyzed by the computer, and CO is calculated via the basic premise that a slow temperature change corresponds to a low CO, and a quick temperature change corresponds to a high CO. Thus, the degree and speed of change in temperature are directly proportional to CO with the thermodilution technique. About three to four repeated measurements are taken to ensure accuracy. 3. Comparison of the Fick and thermodilution techniques. It is important to recognize the advantages and shortcomings of the Fick and thermodilution techniques when considering a method to calculate CO (or valve area). The Fick equation is most accurate when O2 consumption can be directly measured, as actual O2 consumption differs from the assumed 125 mL/min/m2 by up to 25% in many patients, or even more in those with a systemic stressor (such as sepsis). Also, Fick is most accurate in patients with normal or low CO, as large A-V O2 saturation differences (as in high CO states) are more likely to introduce error. In contrast, the thermodilution method is dependent on accurate measurement of blood and injectate temperature, and CO will be overestimated if the injectate temperature is inappropriately increased by allowing it to remain too long in the syringe or holding it by hand during injection. Similarly, the thermodilution technique is most accurate in normal or high-flow states due to warming of the blood by the cardiac chambers in low-flow states. Additionally, it is unreliable in the presence of severe TR. 4. Other techniques. Angiographic measurement of SV is possible via estimation of LV end-diastolic and end-systolic volumes via left ventriculography. When multiplied by HR at the time of ventriculography, this can estimate CO. However, this method is rarely used, as it is prone to error in patients with an irregular

rhythm, and estimation of LV volume is challenging on angiography alone. III.

VALVULAR PATHOLOGY A. Calculation of valve orifice area 1. Gorlin formula. Invasive calculation of valve orifice area (VOA) is most often performed via the Gorlin formula, which relies on the CO, mean pressure gradient across the valve (ΔP), and flow period (the portion of the cardiac cycle during which blood flows across the valve). Thus, the systolic ejection period (SEP) is used for the AV and PV, and the diastolic filling period (DFP) is used for the mitral valve (MV) and TV. Based on the Gorlin equation, calculation of VOA is:

where VOA is in cm2, CO in mL/min, HR in beats/min, and SEP and DFP in sec/beat. C is an empiric constant of 1.0 for all valves except the MV, where it is 0.85. 2. Hakki formula. The Hakki formula is a simplified form of the Gorlin equation, based on the observation that at normal HR, the product of HR, SEP, or DFP is approximately 1 for most patients.

A limitation of the Hakki formula is that SEP and DFP change markedly with tachycardia. To deal with this, Angel has suggested a correction for HR, such that the Hakki formula should be divided by 1.35 when the HR is >90 bpm for AS and 30 mm Hg. Outcomes with balloon valvuloplasty are generally good and PS does not often recur (Fig. 20.9). G. Pulmonic valve regurgitation. Significant pulmonic valve regurgitation (PR) is uncommon and usually seen in congenital heart disease, as a consequence of surgical repair or valvuloplasty, or as a result of endocarditis. Patients with severe PR may have a widened PA pulse pressure, a fast dicrotic collapse, and rapid equilibration of the RVEDP and PA EDP. As the PA waveform appears similar to the RV, there is “ventricularization” of the PA tracing. Unlike in AR and MR, contrast injection is not useful in quantifying the severity of regurgitation in PR. H. Tricuspid valve stenosis. Severe TS is uncommon and usually caused by rheumatic heart disease in association with MS. Rarely, it can be seen in other conditions, such as carcinoid syndrome. In TS, RA emptying is obstructed and RV filling impaired. As such, RA pressure is elevated, and patients may have a large “a” wave. Hemodynamic tracings demonstrate a diastolic gradient between the RA and RV. Similar with other valves, simultaneous measurement of RV and RA pressures allows for precise measurement of the TV gradient and calculation of tricuspid VOA via the Gorlin or Hakki equations. Like in AS or MS, concomitant TR will result in underestimation of the VOA because the actual transvalvular flow is confounded. It should be noted that the Gorlin equation has not been validated in TS, although

small series suggest that the calculated VOA correlates with the true valve area in patients who undergo surgery.

FIGURE 20.9 Pulmonic stenosis before and after balloon valvuloplasty. This is an example of reduction in right ventricular (RV) peak systolic pressure. PA, pulmonary artery.

FIGURE 20.10 Tricuspid regurgitation. A: Similar to the left atrium with mitral regurgitation, there may be large “v”-waves visualized on the right atrial (RA) tracing in patients with significant tricuspid regurgitation, resulting in complete “ventricularization” of the RA tracing. B: The same patient’s right ventricular (RV) pressure tracing.

I. Tricuspid valve regurgitation 1. TR is the most common right-sided valvular problem, observed in many conditions including congenital abnormalities, rheumatic heart disease, pulmonary hypertension, and RV failure, among others. Mild TR is very commonly seen, yet of no clinical significance. Severe TR can cause RA and RV volume overload and eventual RV failure. 2. The hemodynamic findings of TR include RA pressure elevation, distortion of the RA pressure waveform, and corresponding elevation of jugular venous pressure. In TR, the x-descent is blunted, and eventually disappears as the severity of TR worsens. Eventually, the x-descent is replaced by a systolic wave corresponding to RV contraction, termed a c-v wave, with a “peakdome” contour. The v-wave is followed by a brisk y-descent; thus, the RA waveform may appear similar to the RV waveform, and

“ventricularization” may occur (Fig. 20.10). It should be noted that while supportive of severe TR, these findings are not always seen, especially in patients with atrial fibrillation and hypovolemia (as regurgitant volume is dependent on RV volume).

KEY PEARLS • Invasive hemodynamic assessment of valve disease is indicated when results of noninvasive tests are inconclusive or discrepant with the clinical severity of valve disease. • Knowledge of normal hemodynamic values and pressure waveforms is essential to interpret the pathologic hemodynamic findings in valvular heart disease. • The most common technique used to calculate CO is the Fick equation:

where most laboratories use an assumed value for O2 consumption of 125 mL/min/m2. • An alternative for CO measurement is the thermodilution technique, which measures the change in temperature of PA blood over time after saline injection. • Fick is less accurate in high-flow states, in situations of high O2 demand (i.e., fever or sepsis), or intracardiac shunting. The thermodilution method is less accurate in low-flow states or in the presence of significant TR. • The most widely used formula to calculate VOA of any valve is the Gorlin equation:

where C is an empiric constant of 1.0 for all valves except the MV, where it is 0.85. • The Hakki formula is a simplified form of the Gorlin equation:

To correct for HR, the Hakki formula should be divided by 1.35 when HR is >90 bpm for AS and > LA pressure, diastolic MR may occur. In contrast, in chronic AR there may be preserved SBP with a widened pulse pressure, and a normal to slightly elevated LVEDP due to gradual accommodation of LV compliance. • Transvalvular gradients for MS are obtained with simultaneous LV pressure and LA (or

PCWP) measurement. Classic findings are presence of a diastolic gradient greatest in early diastole, as well as prominent “a” and “v” waves on LA and/or PCWP tracings. • In acute MR, there are typically large “v” waves on LA or PCWP tracings, which are smaller in chronic MR due to an increase in LA compliance over time. • Severe AR and MR are graded on the basis of the amount of contrast regurgitation during sequential cardiac cycles. • Both PS and PR are uncommonly encountered in adults. While valve area can be calculated via the Gorlin or Hakki equations, a mean systolic gradient >40 mm Hg in asymptomatic patients and >30 mm Hg in symptomatic patients is typically used as a threshold to pursue balloon valvuloplasty or surgery. • In severe TS, there may be large “a” waves on RA tracing. In severe TR, there may be large c-v” waves with a “peak-dome” contour on RA and central venous pressure tracing.

SUGGESTED READINGS Angel J, Soler-Soler J, Anivarro I, et al. Hemodynamic evaluation of stenotic cardiac valves, Part II: modification of the simplified valve formula for mitral and aortic valve area calculation. Catet Cardiov Diagn. 1985;11:127–138. Biam DS, Grossman W, eds. Cardiac Catheterization, Angiography and Intervention. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1996. Hakki AH, Iskandrian AS, Bemis CE, et al. A simplified valve formula for the calculation of stenotic cardiac valve areas. Circulation. 1981;63:1050–1055. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease. J Am Col Cardiol. 2014;63(22):e57–e185. Ragosta M. Textbook of Clinical Hemodynamics. 1st ed. Philadelphia, PA: Saunders; 2008.

I.

INTRODUCTION In this chapter, we will review the calculations used to quantitatively assess valvular stenosis and regurgitation by Doppler echocardiography. We will first review the necessary equations and data that must be acquired, along with how the results are calculated and used to assess valvular stenosis or regurgitation severity. We will also discuss potential pitfalls in performing these calculations. Finally, we will present several cases that demonstrate how to apply these calculations using real echocardiographic data.

II.

CALCULATIONS: AORTIC VALVE A. Aortic stenosis 1. Aortic stenosis (AS) severity is assessed by Doppler and twodimensional (2D) echocardiographic imaging capabilities. Peak aortic flow velocity, peak aortic valve (AV) gradient, mean AV gradient, aortic valve area (AVA), and the dimensionless index (DI) all in combination with 2D appearance of the valve are required to derive a determination of stenosis severity. The aortic flow velocity is a measured variable that is acquired using continuous-wave (CW) Doppler echocardiography with the cursor aligned parallel to flow across the AV from either the apical 5-chamber (A5C) or apical 3-chamber (A3C) window. Additionally, data can be acquired from the right parasternal border, suprasternal notch, and subcostal windows. A dedicated Doppler Pedoff probe can be used to assure maximal velocities are obtained from each imaging plane.

The highest values obtained, reported as Doppler velocities, are usually underestimated when images are off axis, as only the component of the velocity vector parallel to the Doppler signal is measured. The peak aortic gradient is calculated from the peak velocity, usually using the simplified Bernoulli equation (if subaortic velocity is 64

Mean gradient (mm Hg)

40

Aortic valve area (cm2)

>1.5

1.0–1.5

0.5

0.25–0.5